Regin App -

ReGin Home Care LLC

Caregiver Employment Application

Thank you for your interest in joining ReGin Home Care LLC. We are seeking compassionate, dependable, respectful, and professional caregivers who are committed to helping individuals remain safe, comfortable, and independent in their homes.

Please complete this application accurately and completely. Submission of an application does not guarantee employment.

ReGin | New Job Application Form

SECTION 1 - Applicant Information

Full Legal Name (First, Middle, Last)

Telephone

Address

Home Address

City / State / ZIP Code

Are you at least 18 years old?

Yes

SECTION 2 - Position Availability

Position Applying For:

Certified Nursing Assistant (CNA)

Home Health Aide (HHA)

Caregiver / Direct Care Worker

Available Start Date

Schedule Interested In (select all that apply):

Full-time

PRN / As needed

Weekends

Evening shift

Part-time

Weekdays

Day shift

Overnight shift

Willing to work holidays?

Yes

Willing to work weekends?

Yes

Occasionally

Days Generally Available:

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

General Hours of Availability

SECTION 3 - Eligibility & Transportation

Are you legally authorized to work in the United States?

Yes

If hired, appropriate documentation verifying identity and work authorization will be required.

Would you be willing to drive a client if an assignment requires it and you meet ReGin Home Care's driving requirements?

Yes

Do not submit a copy of your driver's license with this initial application.

Do you have reliable transportation to assigned client locations?

Yes

Do you currently have a valid driver's license?

Yes

SECTION 4 - Caregiving Experience

Do you have previous caregiving or direct-care experience?

Yes

Approximate years of caregiving experience:

Less than 1 year

1-2 years

3-5 years

More than 5 years

Areas of experience (select all that apply):

Bathing / Showering

Bed baths

Dressing

Grooming / Hygiene

Toileting

Incontinence Care

Ambulation / Mobility

Meal Preparation

Transfers

Medication Reminders

Companionship

Respite Care

Light Housekeeping

Memory Loss / Dementia Support

General Safety Supervision

Laundry

Other

Have you worked for a home care agency, assisted living community, nursing facility, hospital, or other healthcare organization?

Yes

SECTION 5 - Education, Training & Certifications

Highest level of education completed:

High School Diploma

Some College

Bachelor's Degree or Higher

GED

Associate Degree

Other

Current certifications/training (select all that apply):

CNA certification

CPR certification

Direct Care Worker / Caregiver training

Other relevant certification/training

Home Health Aide (HHA) training/certificate

First Aid certification

Dementia / Alzheimer's care training

None

List any additional caregiving-related training or certifications

For online application: Résumé and relevant certification uploads may be provided through the secure application form. Do not submit Social Security cards, passports, driver's licenses, banking information, or medical records with this initial application.

SECTION 6 - Employment History

Most Recent Employer

Employer / Company Name

City and State

Position / Job Title

Dates Employed

Primary Responsibilities

Reason for Leaving

Previous Employer

Employer / Company Name

City and State

Position / Job Title

Dates Employed

Primary Responsibilities

Reason for Leaving

SECTION 7 - Professional References

Please provide two professional references who can speak about your work experience, reliability, or character. Please do not list immediate family members.

Reference #1

First Name

Company / Organization (if applicable)

Reference Email

Relationship to Applicant

Phone Mobile

Reference #2

First Name

Company / Organization (if applicable)

Reference Email

Relationship to Applicant

Phone Mobile

SECTION 8 - Caregiver Screening Questions

Why are you interested in working as a caregiver with ReGin Home Care?

What does compassionate care mean to you?

How would you respond if a client refused assistance with a task included in their care plan?

What would you do if you noticed a significant change in a client's condition or behavior?

What qualities do you believe make someone an excellent caregiver?

SECTION 9 - Employment Screening Acknowledgement

I understand that employment with ReGin Home Care LLC may be contingent upon successfully completing applicable pre-employment requirements. Depending on the position and applicable Pennsylvania requirements, these may include verification of identity and authorization to work, employment and reference verification, criminal background screening, competency evaluation, training requirements, and verification of applicable certifications. I understand that additional disclosures, authorizations, and documentation may be required separately before any applicable background screening is conducted.

I acknowledge that I have read and understand the statement above.

SECTION 10 - Applicant Certification

By submitting this application, I certify that the information I have provided is true and complete to the best of my knowledge. I understand that providing materially false or misleading information or omitting material information may affect consideration for employment or, where permitted by law, continued employment. I understand that submitting this application does not constitute an offer or guarantee of employment.

Applicant Full Name

Applicant Signature (Or Print Your Full Name)

Date / Time

I certify that the information provided in this application is true and complete to the best of my knowledge.

Thank you for your interest in ReGin Home Care LLC.

Licensed Pennsylvania Home Care Agency.

Quick Links

Home
About Us
Our Services
Why Choose Us
Job Application
Contact

Home
About Us
Our Services
Why Choose Us
Job Application
Contact

Reach Out!

Address: ReGin Home Care LLC York, PA 17404
Phone: 717-870-2657
Email: info@reginhomecare.com