Fill out this form and let us know what times you have available. Thank you!

Please provide specific times you are available to work. If you are available only for fill in shifts please note that as well.

Name

Phone

What is the best phone number to reach you?

(###)

###

####

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Work Types

Please check each task you would be comfortable providing?

Housekeeping/Laundry

Transfer Assistance

Overnight Care

Personal Care (i.e bathing, dressing)

Transportation

Supervision/Caregiver Respite

Dementia Care

Additional Information

For Example: - Start date of new availability - Any additional work preferences: - Client types - Shift location (Eudora, Baldwin, Rural, Lecompton, Lawrence) - Any other information we need for staffing

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