Caregiver Registration

Online Caregiver Registration

Full Name(*)
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Cell Phone(*)
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Address(*)
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City
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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.

Date of Submission
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(*)
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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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Make Us Your Source for All Your Private Home Care Needs!

Serving Southeast Florida:

  • Martin County
  • St Lucie County
  • Palm Beach County
  • Okeechobee County
  • Indian River County

Serving Central Florida:

  • Brevard County
  • Orange County
  • Osceola County
  • Seminole County

Serving Southwest Florida:

  • Lee County
  • Collier County
  • Charlotte County
  • Sarasota County
  • Hendry County
  • DeSoto County
  • Glades County

Our Locations

Southeast Florida
2500 S Kanner Hwy, Suite 1, Stuart, FL 34994
Phone: (772) 220-6005 ~  Fax: (772) 220-5867

Palm Beach County
Phone: (561) 585-4535 ~ Fax: (561) 585-3847

Southwest Florida
14440 Metropolis Avenue, Suite 103, Ft Myers, FL 33912
Phone: (239) 690-9969 ~  Fax: (239) 690-9971

Naples Florida
1415 Panther Lane, Ste 214, Naples, FL 34109
Phone: (239) 591-6760 ~  Fax: (239) 690-9971

Melbourne Florida
100 Rialto Place, Suite 705, Melbourne, FL, 32901
Phone: (321) 541-1248 ~  Fax: (321) 541-1249