Mississauga Application Form Mississauga Application Form Job Posting ReferenceApplicant's Full Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY What is your gender identity? (Optional) Male Female Non-Binary Prefer not to say Other Phone(Required)Email(Required) Address(Required) Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code Referred By:Have you worked with this agency previously:(Required) Yes No If YES what year(s)?How many years experience do you have in this industry?(Required)Are you a Personal Support Worker?(Required) Yes No Do you take public transportation?(Required) Yes No Do you have your own vehicle for work?(Required) Yes No Number of COVID Vaccines Received?(Required)Do you have a current (within 1yr of this application date) Vulnerable Police Check?(Required) Yes No Optional: Cultural BackgroundAt Ideal Caregivers 4U, we value cultural compatibility as part of providing respectful, person-centered care. Some of our clients request caregivers who share a similar cultural or language background. This section is optional and is used only to support appropriate client-caregivermatches.If you are comfortable, please let us know how you identify: Black / African / Caribbean East Asian (e.g., Chinese, Japanese, Korean) South Asian (e.g., Indian, Pakistani, Sri Lankan, Bangladeshi) Southeast Asian (e.g., Filipino, Vietnamese, Thai, Cambodian) Indigenous (First Nations, Métis, Inuit) Middle Eastern / North African Latino / Hispanic White / Caucasian Prefer not to say Other Some clients may request a caregiver who speaks a particular language to ensurecomfort and clear communication. Please list all the languages you speak fluently orconversationally.DocumentsDocuments Required to be emailed to us (if applicable):info@idealcaregivers4u.com Att: Mags PSW Certificate Any training certificates CPR Certificate First Aid Certificate TB tests Government photo Identification Vulnerable Police Check Previous Work History (2+ Years)Company 1 NameCompany 1 PhonePositionStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Company 2 NameCompany 2 PhonePositionStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Company 3 NameCompany 3 PhonePositionStart Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Additional work history in the past 2+ years:Professional ReferencesReference #1 First Last Reference #1 PhoneReference #1 Position/Relationship to youReference #2 First Last Reference #2 PhoneReference #2 Position/Relationship to youReference #3 First Last Reference #3 PhoneReference #3 Position/Relationship to youAvailabilityPlease state your availability below in as much detail as possible. Due to the nature of the business, no guarantee can be made as to the schedule, or the number of hours worked.What date are you available to begin work?(Required) MM slash DD slash YYYY Weekdays/Times(Required)Please indicate the days of the week that you are available and the exact times in the day that you are available so that we can schedule shifts accurately. Monday Tuesday Wednesday Thursday Friday Saturday Sunday Monday Times Morning Afternoon Evening Overnights Tuesday Times Morning Afternoon Evening Overnights Wednesday Times Morning Afternoon Evening Overnights Thursday Times Morning Afternoon Evening Overnights Friday Times Morning Afternoon Evening Overnights Saturday Times Morning Afternoon Evening Overnights Sunday Times Morning Afternoon Evening Overnights Are you willing to provide service to a client with a pet?(Required) Yes No Which animals? Cats Dogs Both Are you willing to provide service to a client that smokes?(Required) Yes No Areas willing to work: Mississauga East Mississauga West Mississauga (Downtown) Mississauga South Your Full Legal Name First Middle Last Signature(Required)Date Signed MM slash DD slash YYYY
