Parent
Family Registration Form
For Eldercare
Companion
Information on Contact Person:
Your First Name:
Your Last Name:
Occupation(s):
Street Address:
City:
Province:
Postal Code:
Relationship to Elderly:
Day Phone:
Evening Phone:
Email Address:
Fax Number:
Job Start Date:
Information on Elderly Person(s):
First Name:
Last Name:
Ages of Elderly Person(s)
Street Address:
City:
Province:
Postal Code:
Any Illnesses or Disabilities? Please
explain
Specific Needs or Concerns
regarding Elderly Person(s):
Type of Caregiver
Required:
Describe age,
personality/skills preference of Caregiver:
Does your Caregiver need to be a non-smoker?
Does anyone in your household smoke in the home?
Drivers License Required?
Y/N:
Own Vehicle Required? Y/N:
Can you provide a vehicle for the
Caregiver? Y/N:
Schedule required:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Weekly Hours Required:
Describe
the hours and duties, ie: 9:00am-5:00pm:
Will there be occasional overtime?
Y/N:
Wages Prepared to Offer:
Will you be paying vacation pay, stat pay, overtime?
Y/N:
Brief job description/duties required:
Prepare
Lunches
Prepare
Dinner
Shop
for Groceries
Run
errands (ie: pay bills, pickup supplies, etc)
General
Housekeeping Duties
Perform
Laundry Duties
Change
Linens
Make Beds
Driving
to and from appointments
Reminding
to take medications (please note the caregiver is not qualified to
'administer' medications)
Social
Outings and Activities
Other,
please explain
Time commitment required - short-term (less than 6 months),
Long-term 1 year+:
Pets in the home, if yes please specify:
For Live-in only, please describe the
Caregiver living arrangements
available:
