Online Application

Please fill-out the following form if you are interested in being a caregiver with Champion Home Health Care. You will be contacted by us after we have reviewed your submission.

Initial HHA contractor application

• Name*full name
  0
• Address*full address
  1
• Email*a valid email address
  2
• Phone*
  3
• Date of birth*
  4
• Social Security #*
  5
• Check those of which you have a valid, current copy.*

  Florida CNA License

  AHA or Red Cross CPR Certificate

  Social Security Card

  Driver's License

  Auto Insurance

  Passport
  6
• Availability:
  7
• Please describe your weekly availability*including weekends
  8
• References
  9
• Name 1*full name
  10
• Phone 1*
  11
• Name 2*full name
  12
• Phone 2*full name
  13
• Please list three most recent client, contractees or employees.
  14
• Company Name 1*
  15
• Supervisor/Client Name 1*
  16
• Dates of Work 1*Enter range
  17
• Contact Phone 1*
  18
• Company Name 2*
  19
• Supervisor/Client Name 2*
  20
• Dates of Work 2*Eneter range
  21
• Contact Phone 2*full name
  22
• Company Name 3*
  23
• Supervisor/Client Name 3*full name
  24
• Dates of Work 3*
  25
• Contact Phone 3*
  26
• 27
• Emergency Contact Name*full name
  28
• Emergency Contact Number*
  29
• DL State*
  30
• DL Exp Date*
  31
• Name as it appears on Social Security Card*full name
  32
• Driver’s License #*
  33
• Thank you for providing the information to get you started with Champion Home Health Care. What to expect now:

  1. Please expect a call from one of our hiring managers to set you up for an interview.
  2. After the interview, you will be set up to do the initial in-services and written test that Champion requires. You will also take an on-line course to explain the procedures the contractors need to follow when providing services to the clients.
  3. The sooner you complete the training, the sooner we can schedule your meet and greet with the office staff and be on your way to providing care through the best home health agency in the region. We automatically receive notification of your successful completion of all the in-services and training.
  4. We will call you to set up the meet and greet. We expect you to dress in scrubs (any color) and attire like if you were going to work. Please bring the following items to your meet and greet
     • Blue pen
     • Phone
     • Driver's license
     • Social security card or passport/other acceptable gov't ID card auto insurance
     • AHA or red cross CPR card
     • FL CNA certificate or 75 hr HHA certificate

  Plan to be here for an hour for the informational meet and greet.
  34
• #ddd
  35

powered by FormCraft form builder