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2110 Powers Ferry Rd Suite 306, Atlanta, 30339 GA
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Home
Services
Live-in Care
Veterans Care
Personal Care
Companionship
Specialized Care
About
Why Choose Us
Our Focus
Screening Our Aides
Demographics & Trends
Senior Resources
Testimonials
Our Care Providers
News Coverage
Care Providers
Timesheet
Employment
Referrals
FAQs
How Can I Pay?
Blog
Careers
Service Areas
Contact
Schedule Consultation
Apply for a Home Care Job with Options for Seniors America
Step
1
of
5
20%
Personal Information
Name
(Required)
First
Middle
Last
Address Line 1
(Required)
City
(Required)
State
(Required)
Zip Code
(Required)
Email:
(Required)
Home Phone:
Cell Phone
(Required)
Gender
(Required)
Male
Female
Open to Live-In Care
(Required)
Yes
No
Convicted of a felony?
(Required)
Yes
No
Vehicle Information
Vehicle Year
(Required)
Vehicle Make
(Required)
Driver's License
(Required)
Yes
No
Experience
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?
(Required)
Yes
No
Result
(Required)
Positive
Negative
Work Preference
Date Available
MM slash DD slash YYYY
Ideal Number of Hours Per Week
Expected Rate of Pay/hr
(Required)
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
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
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Consent
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