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Direct Line : John – (630) 470-2414
john@samaritanseniorcare.org

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Samaritan Senior Care helps families use their Long-Term Care Insurance benefits.
We assist with documentation and billing required for reimbursement.

Application Form

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Date

MM slash DD slash YYYY

Full Name*

First Name Middle Name Last Name

Address*

Home Phone

Email*

Cell Phone*

Date of Birth*

MM slash DD slash YYYY

Social Security Number*

Your Immigration Status*

Citizen

Green Card Holder

Work Visa

Are you eligible to work in the United States?*

Yes

No

Gender*

Male

Female

Open to Live-In Care*

Yes

No

Convicted of a felony?*

Yes

No

Vehicle Information

Vehicle Year

Vehicle Make

Driver's License*

Yes

No

Experience

Untitled

Alzheimer's

Bed Bath

Cancer

Combative

Dementia

Dementia Experience

Gait Belt Experience

Glucose Monitor

Hospice

Hospice Experience

Hoyer Lift Experience

Incontinence

Parkinson's

Stroke

Have you had a TB test in the last 3 years?

Yes

No

Result

Positive

Negative

How did you hear about us?

Emergency Contact Name

Emergency Contact Phone

Work Preference

Date Available

MM slash DD slash YYYY

Ideal Number of Hours Per Week

Shift Availability

Monday

Morning

Afternoon

Evening

Live-In

Tuesday

Morning

Afternoon

Evening

Live-In

Wednesday

Morning

Afternoon

Evening

Live-In

Thursday

Morning

Afternoon

Evening

Live-In

Friday

Morning

Afternoon

Evening

Live-In

Saturday

Morning

Afternoon

Evening

Live-In

Sunday

Morning

Afternoon

Evening

Live-In

Education

School Name

Subject Studied

Years Attended

Location

Degree

School Name

Subject Studied

Years Attended

Location

Degree

Reference

First Reference

Name

Relationship

Phone

Years Known

Second Reference

Name

Relationship

Phone

Years Known

Describe any personal, volunteer or work related experiences that will help you in this position:

Employment History

Present/Last Employer

Employer Name

Telephone

Supervisor's Name

May we contact?

Yes

No

Address

Position Title

From Date

MM slash DD slash YYYY

To Date

MM slash DD slash YYYY

Summary of Duties

Reason for Leaving

Previous Employer

Employer Name

Telephone

Supervisor's Name

May we contact?

Yes

No

Address

Position Title

From Date

MM slash DD slash YYYY

To Date

MM slash DD slash YYYY

Summary of Duties

Reason for Leaving

Certify

Consent

By signing this application, I certify this information to be true and agree to allow the above mentioned Home Care Agency to perform a criminal history background check, at their leisure, and I give permission for them to check my references.

Full Name*

Date*

MM slash DD slash YYYY

Signature*

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Phone

Direct Line : John – (630) 470-2414

Email

john@samaritanseniorcare.org
hello@samaritanseniorcare.org

Address

Oakbrook Terrace Office (Main Office): 18W140 Butterfield Rd, 15th Floor, One Lincoln Centre, Oakbrook Terrace, IL 60181
Naperville Office: 50 S Main St, Ste 200, Naperville, IL, 60169
Hoffman Estates Office: 2300 Barrington Rd, Ste 470, Hoffman Estates, IL 60169

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About
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Contact

About
Blog
Service Areas
Careers
Contact

About
Blog
Service Areas
Careers
Contact

About
Blog
Service Areas
Careers
Contact

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