Canada Atlantic Caregiving Solutions

Quality Placements For Canadian Families
Live-In Live-Out Part-Time

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Employer's Application For Senior Care Form

Please Note!!
If you applying for nanny care, please apply here.

Please fill in this form with as much detail as possible so we may match you with the most suitable caregiver.

Required Fields **

Personal Information

** First Name:

** Last Name:

** Street Address:

** City/Town:

** Province:

** Postal Code:

** Telephone Number:

** Email Address:

General Information

** What type of caregiver do you require?
Live In Live In Disabled/Special Care Live In Companion
Live Out Live Out Disabled/Special Care Live Out Companion

** If live-in do you have a private and furnished bedroom for the caregiver?
Yes No

** Do you allow smoking in your home?
Yes No

** Is the employer/parent on medication? If so, please explain:

** Does the employer/parent have special dietary or allery considerations? If so, please explain:

** Is the employer/parent able to walk or need assistance for walking. Please explain:

** Does the employer/parent have an ongoing medical condition? Please explain:

** Does the employer/parent have any mental challenges? Please explain:

** Will personal care be needed for the employer/parent? Please explain:

** Will the caregiver accompany the employer/parent to doctor's appointments and other activities? Please explain:

** How do you think the employer/parent will interact with the new caregiver? Please explain:

** Do you have pets? If yes, what part of their care will the nanny be responsible for?
Please explain:

** If needed, is lifting/transfer equipment available for the caregiver to use? Please explain:

** If needed, what other types of equipment is available? Please explain:

** What are your ideal qualitities for a caregiver? Please explain:

** If live-in would you consider the caregiver as a member of your family or as an employee?
Please explain:

** Please describe your family (hobbies, life style, home activities, etc.)

Caregiver Information

** If live-in would the caregiver be allowed visitors? Please explain:

** If live-in would the live in caregiver have a curfew? Please explain:

What is the proposed weekly work hours and gross wages for the caregiver? Please explain:

** Will the caregiver be required to work overtime or work irregular shifts? Please explain:

** If live-in please describe the features of the nanny's bedroom:

Miscellaneous Information

** Is this your first time hiring an employee of any kind?
Yes No

** Are you familiar with payroll procedures?
Yes No

** How did you hear about us? Please explain:

** Do you have any other comments that might be helpful to us in assisting you:

Although there isn't any obligation to hire a caregiver, by submitting this form, you agree that you have read and understand the Terms & Conditions

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