Caregiver Request Form

Thank you for your interest in hiring a graduate from the Professional Home Caregiver Training Program. Please complete this form, providing as much detail as you can. This will help us to match you with a Caregiver that will best meet your needs. Please click here if you prefer to print out this form and complete it.

    Requestor’s Contact Information

    Contact Information for Person Receiving Care (if different from above)

    Does the person in need of care speak English?

    YesNo

    What is their primary language?:

    How did you hear about the Professional Home Caregiver Training Program

    FamilyFriendWebsiteChurchOther

    (please specify):

    (please specify):

    Position Information

    Do you prefer:

    A MaleA FemaleNo Preference

    Frequency:

    Days care is needed (check all that apply):

    Time of day that care is needed (check all that apply):

    Do you require a caregiver that is certified in CPR/First Aid?
    YesNoNo Preference

    Duties needed:

    Additional Information

    Do you have pets?

    NoYes

    Type:How many pets do you have?

    Please briefly describe the responsibilities of the position, tasks expected of the caregiver, and any requirements of the candidate you are seeking.

    Statement of Understanding

    Christian Community Service Center (CCSC) is a not-for-profit organization. CCSC provides a resource center for job seekers. It is not an Employment Placement Agency, nor does it engage in the business of placing clients directly with employers. Businesses or individuals seeking employees can list their job openings with CCSC free of charge. This is no guarantee that a qualified candidate will be available for the position(s) listed, and it is the responsibility of the client to contact the employer for additional information. CCSC does not receive any direct remuneration from businesses or individuals that find employees through its services. CCSC conducts a crime records search with the Texas Department of Public Safety and an employability status check search with the Texas Department of Aging and Disability Services for all participants in the Professional Home Caregiver Training Program at the time of enrollment. Individuals with felony or violent convictions are ineligible for program participation. Other convictions are evaluated on a case-by-case basis. Relevant findings from this search will be shared with interested employers. It is the sole responsibility of the prospective employer to check references, immigration status, and any other applicable background information. No guarantee is either expressed or implied as to the correctness of information provided by the clients in the application form.

    Digital Signature

    Note: Please type First and Last name in the box

    Volunteer at CCSC

    Get Involved!

    YOU can help make a difference in our community – volunteer today!

    Read More