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Introduction
Live-In Caregiver Program
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Application Form
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**Please be totally honest when filling out the application form, as we cannot place you with a good match unless we know the correct information. Failure to fill out the form completely will result in the inability to process your application**
*Required Fields
*Surname:
Middle Name:
*First Name
Address :
*Email Address:
Phone Number:
Preferred Method of Communication :
Email
Phone
Best Time To Contact You :
Can we (SMS) you as a last resort of communication if we cannot contact you via your preferred method:
Yes
No
Personal Information
Date of Birth
Sex:
Male
Female
Height:
Below 4 feet
4 ft 10 in
4 ft 11 in
5 ft 0 in
5 ft 1 in
5 ft 2 in
5 ft 3 in
5 ft 4 in
5 ft 5 in
5 ft 6 in
5 ft 7 in
5 ft 8 in
5 ft 9 in
5 ft 10 in
5 ft 11 in
6 ft 0 in
6 ft 1 in
6 ft 2 in
6 ft 3 in
6 ft 4 in
Above 6ft 4in
Weight
Marital Status :
Married
Unmarried
Divocee
Number of Children:
Where do they live:
Nationality:
Passport Number:
Address in Home Country:
Languages Spoken :
Religious Affiliation:
Work Information
Please list all the countries you have worked in and how long:
How long have you been in Hong Kong?
Arrival Date:
JOB 1
Employer’s Name:
Address :
Home Telephone:
Office Telephone :
Employment Start and End Date:
Salary:
List Regular Duties :
Number of children/elders you take care of and there age:
Contract end date:
JOB 2
Employer’s Name:
Address :
Home Telephone:
Office Telephone :
Employment Start and End Date:
Salary:
List Regular Duties :
Number of children/elders you take care of and there age:
Contract end date:
JOB3
Employer’s Name:
Address :
Home Telephone:
Office Telephone :
Employment Start and End Date:
Salary:
List Regular Duties :
Number of children/elders you take care of and there age:
Contract end date:
Childcare/Eldercare training:
Midwife
FirstAid/CPR
Nurse
Teacher
Physical Therapist
Other (Please Specify):
Your Skills
Check the boxes you have experience with:
Newborns
Babies
Toddlers
School Aged Children
Teenagers
Twins/Multiple Births
General Housekeeping
Grocery Shopping
Cooking (for Children)
Cooking (For Family)
Disabled Children
Disabled Adults
Disabled Elderly
Laundry
Menu Planning
Elderly
Sewing
Ironing
Serving Parties
Cooking (Gourmet)
At home medical Devices (Glucose monitoring, BP Monitoring etc.)
General Information:
Is your present employer aware you are seeking employment overseas?
Yes
No
May we contact them?
Yes
No
Yes, after I give notice
Do you drive?
Yes
No
Please provide country where your driver’s license is valid
Are you willing to learn?
Yes
No
Please list any skills or hobbies you have that may help you as a caregiver:
Types of food you can cook (eg. Chinese, Italian, Indian, etc)
Please rate your cooking from 1 to 10 (1 being unable to cook and 10 being gourmet):
Can you swim:
Yes
No
Rate your swimming ability from 1 to 10
Do you have any allergies to pets?
Yes
No
If yes, please specify:
Are you willing to care for pets?
Yes
No
Do you have any dietary restrictions?:
Future Job Information
How long would you like to stay with your new employer?
Acceptable Working Locations
Main Cities
Small Cities
Suburbs
Countryside
All
Max # of children you are willing/capable of taking care of:
Are you available to work on Saturdays or Sundays? If not, please explain:
Please list any aspects of caregiving or housekeeping that you are unable or unwilling to perform and why:
Are you willing to travel with the family?
Yes
No
Please provide any details of family or close friends you have in Canada:
Name
City
Relationship
Name
City
Relationship
Name
City
Relationship
If we cannot reach you, we cannot place you!! Please provide an alternate contact and phone number.
Name
Phone
Relationship
I hereby declare the above information is true and I give Familymatch Placement Agency Inc sole permission in assisting me to find an employer in Canada under the Live-in Caregiver Program.
Name
Date
*Security Code :