GOLDEN CONNECTIONS

Companion Application Form

Section 1: Personal Information

First name

Last name

Birthday

Month

Day

Year

social security

Phone

Preferred Contact Method

Choose one of the following

Phone

Section 2: Experience and Skills

1. Why are you interested in becoming a companion with Golden Connections?

2. Have you ever provided companionship or caregiving services before? If yes, please describe your experience.

3. Are you comfortable assisting with tasks such as meal preparation, running errands, or providing transportation?

4. Do you have any certifications or training relevant to caregiving or companionship (e.g., CPR, first aid, or CNA certification)?

5. How soon are you available to start?

Section 3: Lifestyle and Personal Preferences

1. Do you prefer living in a quiet environment, or are you comfortable in more active households?

2. Do you have any dietary restrictions or preferences that would impact shared meal arrangements?

3. Are there specific tasks or responsibilities you prefer not to take on?

Work and Fianacial Stability.

3. Do you currently have a source of income or financial support? (This helps assess their stability.)

4. Are you comfortable with the agreed-upon compensation or rent reduction terms?

5. Do you own a vehicle or have reliable transportation to fulfill responsibilities that may require travel?

6. If relocation is required, will you need assistance with transportation or moving expenses?

References and Background

7. Can you provide references from previous landlords, employers, or clients?

8. Would you consent to a background check as part of the screening process?

9. Are you comfortable responding to emergencies if they arise? If not, are you willing to learn?

Do you have a plan for managing your health or personal needs during an emergency (e.g., natural disasters)?

10. Do you have any pets?

Yes

11. Are you comfortable living with pets? If yes, are there specific types of pets you prefer or would rather avoid?

12. Are you a smoker?

Yes

13. Would you mind living with someone who smokes?

14. Are you tidy or messy in your daily living habits?

15. What time do you usually go to bed?

16. What time do you typically wake up?

Religious Background

17. What is your religious or spiritual background (if any)?

18. Are you comfortable living in a household with a different religious background or beliefs?

Yes

19. What hobbies, interests, or activities do you enjoy that you might share with the senior you’re living with?

20. Are there specific qualities or traits you seek in the family or senior you'll be living with?

References: Give at least one professional reference the other two can be a coworker, friend, or family.

Reference 1

Reference 2

Reference 3

File upload

Date

Month

Day

Year

Signature

Signature field is empty.

GOLDEN CONNECTIONS

Companion Application Form

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