Application - Sweet Tea Home Care

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– Step 1 of 8

Name *

First

Last

Preferred Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Email Address *

Date of Birth *

Social Security Number (for background check) *

Emergency Contact Name *

Relationship *

Emergency Contact Phone Number *

Position Information

Position Applied For (check one only) *

Caregiver
Homemaker
Office Staff
Other

Desired Employment (check one only) *

Full-time
Part-time
PRN (as needed)

Date Available to Start *

How did you hear about us? *

Desired Pay Rate *

Are you authorized to work in U.S.? *

Have you ever worked for a home care agency before? *

Agency Name (type 'n/a' if you selected no) *

Do you have reliable transportation? *

Upload Full Checklist

Are you able to lift 50+ lbs? *

Are you able to work weekends or holidays if needed? *

Education and Training

Highest Educational Level Completed *

Name of School *

City/ State *

Diploma or Degree *

Years completed *

Certifications (CPR, CNA, PCA, other) (please name other) *

Background and Screening Questions

Note: A ‘yes’ answer will not automatically disqualify you.

Have you ever been convicted of a felon or misdemeanor? *

If yes, explain.

Are you listed on any abuse or neglect registry? *

If yes, explain.

Do you have a valid drivers license? *

Do you care auto insurance? *

Can you provide proof of eligibility to work (I-9)? *

Skills and Experience Checklist

Check all that apply: *

Personal Care (bathing, grooming, dressing)
Companionship and Conversation
Meal Preparation
Transportation / Transfers
Hospice or Respite Support
Pet-Friendly

List any special skills or training:

Availability

Check all that apply.

Monday

Morning
Evening
Overnight
Any shifts

Tuesday

Morning
Evening
Overnight
Any shifts

Wednesday

Morning
Evening
Overnight
Any shifts

Thursday

Morning
Evening
Overnight
Any shifts

Friday

Morning
Evening
Overnight
Any shifts

Saturday

Morning
Evening
Overnight
Any shifts

Sunday

Morning
Evening
Overnight
Any shifts

References

Reference 1 – Name *

Reference 1 – Phone *

Reference 1 – Relationship *

Reference 1 – Years Known *

Reference 2 – Name *

Reference 2 – Phone *

Reference 2 – Relationship *

Reference 2 – Years Known *

Documentation

Applicant / New Hire must provide required copies of documentation before starting work. Check all that apply.

Documentation (Please Attach or Upload) *

Required: Drivers License or State ID
Required: Social Security Card or Work Authorization
Auto Insurance (if transporting clients)
CPR / First Aid Certification
Direct Deposit Form
Required: Completed Background Check Consent Form (will be requested if hired)

File Upload – If you are having issues uploading the file is too large.

Drag & Drop Files, Choose Files to Upload You can upload up to 7 files.

If you are experiencing issues uploading your documents through the portal, please email the required documentation to [email protected] in order to complete your onboarding process.

Acknowledgments and Agreements

Please read and select each:

Questions *

I certify that all information provided is true and complete.
I authorize Sweet Tea Home Care to conduct background checks and verify my credentials.
I understand this application does not guarantee employment.
I agree to follow all Sweet Tea Home Care policies, including confidentiality and client rights.
I understand that employment may be terminated at any time, with or without cause or notice

Check all that apply.

Date *

Timer *

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Email *

HIPAA Agreement for Caregiver Applicants

Instructions: Please read each statement carefully and check the box to confirm your agreement. All fields are required.

Full Name *

First

Last

Agreement Statements: *

I understand that Protected Health Information (PHI) includes any personal or medical details that can identify a client.
I agree to keep all PHI confidential and will not share client information outside of Sweet Tea Home Care unless required by law.
I will use PHI only for caregiving duties assigned to me by Sweet Tea Home Care.
I will protect PHI by securing documents, avoiding public discussions, and following all privacy safeguards.
I will not take or send photos, videos, or recordings of clients unless approved in writing.
I will immediately report any suspected breach or misuse of PHI to Sweet Tea Home Care.
I understand that violating HIPAA rules may result in termination of employment and legal consequences.

Acknowledgement:

By signing below, you confirm that you understand and agree to follow HIPAA rules and Sweet Tea Home Care’s privacy policies as part of your application process.

Signature Over Printed Name *

First

Last

Date / Time *

Date

Time

W-9 Form

Completed W-9 Form

File Upload *

Drag & Drop Files, Choose Files to Upload

Contractor Code of Conduct and Policy Acknowledgement

Sweet Tea Home Care Contractor Code of Conduct Policy Acknowledgment 2025 – PRINT

File Upload *

Drag & Drop Files, Choose Files to Upload

Media Consent

Sweet Tea Home Care – Photo Release Agreement

Sweet Tea Home Care – Photo and Video Release Agreement

This Agreement is entered into by and between Sweet Tea Home Care and the undersigned individual.

1. Consent to Record and Capture:

The Participant grants the Company permission to photograph, film, or otherwise capture their likeness, voice, and image in any format, including but not limited to photographs, video recordings, and audio recordings.

2. Authorized Use of Media:

The Participant agrees that the Company may use, reproduce, edit, distribute, and publish the Media for any lawful business purpose, including but not limited to social media, website content, promotional campaigns, training materials, and printed publications.

3. No Compensation:

The Participant understands that they will not receive financial compensation, royalties, or other payment for the use of the Media.

4. No Obligation to Use:

The Company is not obligated to use the Media and retains full discretion over its use.

5. Release of Liability:

The Participant releases the Company, its affiliates, employees, contractors, and representatives from any claims or liabilities arising from the use of the Media, including but not limited to claims for defamation, invasion of privacy, or infringement of rights.

6. Duration and Revocation:

This Agreement remains in effect indefinitely unless revoked in writing by the Participant with at least thirty (30) days’ notice. Revocation does not apply to Media already published or distributed.

Agreement Confirmation:

By signing below, the Participant agrees to the terms above. *

I agree to the following terms.
I do not agree to the following terms.

Name *

First

Last

Date / Time *

Date

Time