SENIORS APPLICATION - Child Care - http://maxpages.com/castleperson/SENIORS

SENIORS APPLICATION

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CPPS SENIORS APPLICATION FORM

For a Canadian Government Approved Live-in Caregiver please complete this form.

Please fill in the blanks. Fields marked with * are Required.

DATE SUBMITTED:

(Todays date)

SENIORS FULL NAME:

(Subject for care)

SENIORS - STREET ADDRESS:

(Location for care)

SENIORS - CITY, PROV:

(Location for care)

SENIORS - POSTAL CODE:

(Location for care)

SENIORS - PHONE:

(Location for care)

SENIORS - EMAIL:

(If active)

SENIORS ACCOMODATION:

(Describe seniors residence)

SENIORS GENDER:

SENIORS AGE:

(Enter correct age)

SENIORS D.O.B.:

dd/mm/yyyy

SENIORS HEALTH:

(Elaborate in comments)

SENIORS AFFLICTION:

Cancer Dementia Parkinsons Diabetes Senility other

(Elaborate in comments)

DESIRED CARE:

(Subject to change)

DATE REQUIRED FOR CARE TO START:

JAN 09 FEB 09 MAR 09 APR 09 MAY 09 JUN 09 JUL 09 AUG 09
SEP 09 OCT 09 NOV 09 DEC 09 2010 2011 2012

(Subject to availability)

(AGENT/ENTITY) - I AM:

The Senior Daughter Son Relative Friend A Corp other

(Elaborate in comments)

(AGENT/ENTITY) - NAME:

If Applicant

(AGENT/ENTITY) - FULL CONTACT ADDRESS:

is the Senior

(AGENT/ENTITY) - PHONE #:

Do Not

(AGENT/ENTITY) - EMAIL:

Complete this Section

(AGENT/ENTITY) - SITUATION COMMENTS (max 300):

(Describe seniors situation)

PHOTOS OF SENIOR:

I Am Authorized to Hire Caregiver ASAP:

(Legal Authorization)

Fees To Be Paid By:

Estate Senior Family Agent combo other

(Designate)

Caregiver Live-in Facilities Include:

Locked Bedroom Shared Bath Phone Personal Storage TV Internet Access

(Check off all available)

I acknowledge having read the CPPS:

Terms &Conditions Service Guarantee Privacy Policy

(Click SUBMIT below)

What To Do Now:

My Comments:

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