Become a Carer

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- Step 1 of 8

Full Name *

Where did you hear about us : *

Did you get referred? (yes/no) *

Enter their name here :

Email *

Phone *

Date of Birth *

Address *

and adaptations Are

Are you legally entitled to work in New Zealand? ( yes/no) *

Interests and Hobbies : *

Why do you want to work for us ? *

Do you have any previous experience in the industry and if so, add it here : *

Have any of your family members been involved in the caregiving industry and if so, add it here : *

Details of experience relevant to position applied for : *

Are you aware we only hire Carers as independent contractors, giving you the freedom to choose who, when and where you want to work? (yes/no) *

Have you worked as a contractor before? (yes/no) *

What do you enjoy most about working with older people? *

Are you comfortable working independently in client homes without direct supervision? *

Details of 2 referees (employer or personal) :

Please give details of two referees whose consent has been obtained and who may be contacted for a confidential reference. Where possible, at least two referees should be able to give work-related information and one of those should have supervised or have been senior to you in your current or most current employment.

Referee 1 *

Referee Email 1 *

Referee 2 *

Referee Email 2 *

Are you restricted to working limited hours? (yes/no) *

If “YES” please elaborate, any other commitments

How many hours per week do you want to work ? *

Are you interested in overnight shifts (9pm - 7am) (yes/no) *

Are you interested in taking elderly on 3hr trips (yes/no) *

Do you have a current full driver’s license (yes/no) *

Is your car registered and warranted (yes/no) *

Is your car insured (yes/no) (copy) *

Are you willing to travel to over 20km for work (not a requirement) (yes/no) *

Do you hold a current First Aid Certificate? (yes/no) *

If not, are you willing to get one: (yes/no)

Do you have any medical, psychiatric or physical condition that could affect your ability to do this type of work : (yes/no) *

Have you had an injury or medical condition caused by gradual process, disease, or infection – eg hearing loss, sensitivity to chemicals, occupational overuse injuries – which the tasks of this job may aggravate or contribute to? (yes/no) *

If “yes” please give details and describe any technical aids or equipment or adaptations to the workplace we would need to make to ensure your health and safety : (yes/no)

Declaration

I declare that all the information I have given is true and that any false or misleading information may result in termination of contract with HOME CARE SERVICES.
I understand that all information provided by me will be held on a confidential basis and that my permission will be sought before any identifying personal details are released to a third party.
I consent to HOME CARE SERVICES undertaking reference checks pursuant to my application for a specific employment position, and recognise that all conducted on a confidential basis, and that HOME CARE SERVICES has the right to maintain confidentiality of this information.
I declare that all information provided by me to HOME CARE SERVICES in this Independent Contractor Application is true, accurate and complete and is not designed to mislead in any way.

I confirm that I have read and understood the statements in the declaration above.