Caregiver Registration

VIP America - Online Caregiver Registration

Full Name(*)
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E-mail(*)
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Phone(*)
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Cell Phone(*)
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Address(*)
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City
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State
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Zip Code
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Primary Emergency Contact Information:

Name
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Phone(*)
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Relationship
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Secondary Emergency Contact Information:

Name
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Phone(*)
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Relationship
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Please tell us a little about yourself.

Skill Level(*)
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What Cities/Counties will you work in?(*)
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List the Days and Hours you are Available.(*)
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Shift Preference(*)
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Do you have any lifting restrictions.
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How did you hear about VIP America?
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Do you Smoke?(*)
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Info needed for clients requiring oxygen.

 
Skilled Nursing Services I provide:

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Specialized
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Personal Care Services I provide:

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List any Restrictions:
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Companion Services I provide:

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Homemaking services I provide:

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Contact Preference:

Type Full Name:
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The typing of your Full Name within this field will be treated as a confirmation that ALL information you submitted is true and above reproach.

Today's Date:
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VIPAmerica,LLC will make every effort to refer cases based on the information provided. Occasionally, a referral may be given that does not meet these requirements entirely. It is at my discretion to accept or decline these cases, based on my availability, the contracted rate, and the client's needs.VIP America does not guarantee a referral.

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