APPLICATION FORM FOR THE LIVE-IN CAREGIVER

Name:
Surname:_Lagman________Given Name_Alma__________ Middle Initial_M.
Home Address: Number, Street _Bo.Calulut City of San Fernando Pampanga
__________________________________________
City/Province/Postal Code _City of Sanfernando Province of Pampamga
2000________________________________________________
Country _Philippines______________________________________________________________
Telephone Number: Home 09266835469_______________________ Business
___________________
Age: ___42__ Date of Birth:(Day/Mo/Yr) _04/02/69 ________________
Country of Birth: _Philippines____________________ Citizen of: (Name of Country)____________
Religion: Roman Catholic________________
Marital Status: Single ____Married _x___ Separated ____ Divorced ____ Widowed_____
Do you have any children? Yes _x__ No ___ If yes, how many? _4___ Ages:
_16 yrs, 13 yrs. 10yrs old (twins)___________
How many brothers/sisters do you have? __6____ Ages-Brothers: ___x_____Sisters: 55, 53, 51, 46,
44, 38
_____
Education - Please list the last two institutions you have attended:
1. Name of Institution ____________________________________________________
From (Mth/Yr)______________ To (Mth/Yr)______________
Level Attained (Name any Diploma, Certificate, Degree obtained)
______________________________________________________________________
______________________________________________________________________
2. Name of Institution ____________________________________________________
From (Mth/Yr)______________ To (Mth/Yr)______________
Level Attained (Name any Diploma, Certificate, Degree obtained)
_____________________________________________________________________
_____________________________________________________________________
What languages do you speak?
(Very well/Average/A little) English __x____French ______Other __Tagalog____
Would you like to further your education in any way while in Canada? Yes_x__
No___
If yes, please indicate what you would like to do:
__study more about
computer____________________________________________________________________
______________________________________________________________________
Employment - Include all child care experience and any other positions held
within the last
five years. Please list your child care experience first.
Name of Family/Organization__Rahmathullah
Khan_____________________________________________
Position/Occupation _CEO Contractor in
Dubai___________________________________________________
Held from_Feb.121998________________To(Mth/Yr)____Feb.24 2011
______________________________
Reason for Leaving ___finished contract_and at the same time, I received my request_documents from
my cousin in Canada._______________________________________________
Name of Family/Organization ______________________________________________
Position/Occupation _____________________________________________________
Held From _________________To (Mth/Yr)__________________________________
Reason for Leaving ______________________________________________________
Name of Family/Organization _______________________________________________
Position/Occupation ______________________________________________________
Held From _________________To (Mth/Yr)___________________________________
Reason for Leaving _______________________________________________________
If you are not employed at present, what activities are you involved in?

Please give details:_social worker in our

barangay_______________________________________________________
______________________________________________________________________
Have you ever done volunteer work? Yes _x__ No ___
If yes, give details:___vaccination assistance in our barangay center
_____________________________________________________
______________________________________________________________________
Have you ever belonged to any clubs, sports teams, or special interest groups?
Yes ___ No _x__ If yes, give details:__________________________________________
What are your hobbies?__cooking_________________________________________________
Do you have training in: a) First Aid? Yes ___ No ___ b) CPR? Yes ___ No ___
If so, please provide a copy of certificate(s).
Do you swim? ___ How well? Strong __ Moderate __ Weak _x_ Afraid of water ____
Do you like pets? Yes _x_ No __ If yes, what kind? Dogs__ Cats __ Birds _x_ Other
__
Do you smoke? Yes ___ No _x__
If yes, how frequently? Occasionally ___ Regularly ___ Heavily ___
Are you allergic to anything? eg. (food, medication, plants, etc.) Yes ___ No
__x_
If yes, give details:________________________________________________________
Person to be contacted in case of an emergency:
Name: _Ma.Liberty Manalang_____________________________ Relationship:
____sister____________
Address:__Bo. Calulut City of San Fernando
Pampanga_____________________________________________________________
___________________________________ Phone No.:
__+639284355644_______________________
Do you have a valid driver's licence? Yes ___ No _x__ If yes, date licence
issued: ________
How frequently do you currently drive? Daily ____Weekly ____Monthly ____Seldom
____
Do you have your own car? Yes ___ No _x__ If not, whose car do you use?
____________
If you don't have a licence, would you be willing to learn to drive in Canada?
Yes _x_ No __
Do you have any friends or relatives living in Canada? Yes _x__ No ___
If so, where: ___Vancouver________________________________________________________
If you are selected, when will you be available to commence working?
_as soon as possible_______________
Do you wish to live-in? Yes__x___No_____
If hired, how long would you like to stay in your new position? 1 yr. ___ 2 yrs.
___ longer _3 yrs__
Placement Preference: (1st. 2nd., 3rd.) City ____ Suburb ___ Country___
Which age group would you prefer to work with?
Babies ___ Toddlers 2 to 5 _x__ Older children ___
Which age group(s) have you worked with in the past?
Babies ___ Toddlers 2 to 5 _x__ Older children ___
Do you mind if the family that selects you belongs to a different religion from
yours? Yes __ No _x_
As a nanny/caregiver, you will be required to perform some or all of the
following duties with respect to the child(ren) in the family:
Prepare meals, Clean child(ren)'s room(s), Feed child(ren), Do child(ren)'s
laundry
Bathe and dress child(ren), Play with child(ren), Make beds, Read with
child(ren)
In addition, you may be requested to assist with other general household duties.
Please indicate
Y (yes) or N (no) your willingness to perform the following:
Make beds _Y__ Cook _Y__ Do dishes __Y_ Dust _Y__ Iron _Y__ Vacuum __Y_

Why do you want to work in Canada_good salary working there and more chances to be migrate
there__________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Why do you want to work as a nanny/caregiver? coz I like and love
children._________________________________________________________________________
__
____________________________________________________________________________
____________________________________________________________________________
Do you see childcare as a career? If not, what are your long term plans?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
How long do you think you would be willing to stay with your employer if you and the family got
along well?
___________until they want me
_________________________________________________________________
____________________________________________________________________________
What do you like about taking care of children?
__when teaching them in their assignments and reading them
stories__________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
How many years of experience do you have working with children?
_2 years__________________________________________________________________________
____________________________________________________________________________
What do you think are your strong points in caring for children? When Im treating them like my own
children____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
What do you like to do with children?
_treat them like my own children, make them a good and God fearing while they growing up
___________________________________________________________________________
____________________________________________________________________________
(a) Do you have any experience caring for the elderly? Yes ___ No x___
(b) Do you have any experience caring for the disabled? Yes ___ No _x__
(c) If "yes" to "a" or "b" above, what do you consider to be your strong points in caring for the
elderly/disabled?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
(d) Why do you want to work as a caregiver for the elderly/disabled in Canada?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
(e) How long would you be willing to stay in this type of position?
____________________________________________________________________
____________________________________________________________________
(f) How much experience do you have working with the elderly/disabled?
Less than 1 year___ 1 - 2 years ___ More than 2 years ___
(g) What was your last position working with the elderly/disabled? Tell us about
the job.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
(h) What is your current occupation?

______none______________________________________________________________
____________________________________________________________________
(i) How do you feel about housework/cooking for the elderly/disabled?
___fine and well_________________________________________________________________
____________________________________________________________________
____________________________________________________________________
(j) What did your last employer like best about you?
__hardworking and honest and loving to their
children__________________________________________________________________
____________________________________________________________________
____________________________________________________________________