Caregiver Applicant Form

Personal Information

* First Name

*Last Name

* Email

* Address Line 1

Address Line 2

* Country

* State/Province

* City

* Zip/Postal Code

*Gender

* Mobile Phone

* Home Phone

*Date of Birth

* SSN

Educational Background New Educational Background

School/College/University

Qualification

Attach Document

Employment History New Employment History

Please provide your latest employer information below.

Employer Name

Phone Number

Address

Country

State/Province

City

Zip/Postal Code

Served From

Served To

Position Held

Attach Document

References New Reference

Name

Phone Number

Miscellaneous Questions

Q.) Do you have experience working directly with people who have intellectual/developmental disabilities?

Q.) Are you willing to sign a Contract Agreement that outlines Independent Contractor (Contractor) terms. This Agreement shall not render the Contractor an employee, partner, agent of, or joint venture with the Exceptional Tours for any purpose. The Contractor is and will remain an independent contractor in [his or her] relationship to Exceptional Tours. Exceptional Tours shall not be responsible for withholding taxes with respect to the Contractor’s compensation hereunder. The Contractor shall have no claim against Exceptional Tours hereunder or otherwise for vacation pay, sick leave, retirement benefits, social security, worker’s compensation, health or disability benefits, unemployment insurance benefits, or employee benefits of any kind.

Q.) Are you willing and able to use your personal vehicle to transport individuals you are contracted to support?

Q.) Are you willing to provide documentation of professional liability insurance, automobile insurance and other documents required by the Department of Human Services?

Q.) Are you able to provide documentation of a clear Criminal Background Check via https://epatch.pa.gov/?

Q.) Are you able to provide documentation of a clear FBI check?

Q.) Our referrals are mostly from the Southeast region of Pennsylvania. Are you willing to travel up to an hour?

Caregiver Application Form

Personal Information

Educational Background New Educational Background

Certifications

Employment History New Employment History

Skills/ Preferences

References New Reference

Miscellaneous Questions

* Caregiver Signature