Tasha Special Touch Kare LLC

Compassionate home care services in Champaign-Urbana, IL, dedicated to enhancing the quality of life for seniors and adults with disabilities through personalized support.

Caregiver Application

Name

First

Last

1. Phone Number

2. Address

3. Apt / Unit / Suite

4. City

5. State

6. Zip Code

🔹 Work Eligibility

7. Are you legally authorized to work in the United States? → Multiple Choice Yes No Required: Yes

8. Do you have a valid Driver's License or State ID? → Multiple Choice

Yes No Required: Yes

🔹 Certifications 🔹

🔹 Certifications

9. → Checkboxes CNA (Certified Nursing Assistant) HHA (Home Health Aide)

10. Years of caregiving experience → Number field

Required: Yes

11. Describe your caregiving experience → Paragraph Text

Required: Yes

12. Do you have experience with any of the following? → Checkboxes

Dementia / Alzheimer’s Hospice Care Transfers / Hoyer Lift Medication Reminders Companionship Personal Care (Bathing, Dressing, Grooming) Meal Preparation Housekeeping

🔹 Availability

13. What shifts are you available for? → Checkboxes

Days Evenings Overnights Weekends Live-in PRN / As Needed

14. Preferred start date → Single Line Text

(You may type a date manually)

🔹References

🔹 References

#2 (Name & Phone) → Paragraph Text

🔹 Final Section

16. Why would you like to work with Tasha Special Touch Kare LLC? → Paragraph Text

17. Signature (type full name) →

(type full name) → Required: Yes