Caregiver Application | WellSky Personal Care

Applicant Information:

First Name*:

Middle Name*:

No Middle Name:

Preferred Name:

Last Name*:

Address*:

Address Line 2:

City*:

State*:

Postal Code*:

Home Phone:

Mobile Phone*:

Email*:

Location:

Hours wanted weekly:

Date Of Birth:

Education & Training:

High School

College

School:

Degree received:

Certifications and Credentials:

Please check all that apply, and enter the expiration date and any notes as applicable.

Active	Type	Expiration Date	Notes
	Background Check
	Car Insurance
	CNA License
	COVID-19 vaccination
	CPR Certification
	Driver's License
	Drug Screening
	EMR/NAR
	First Aid Certification
	HHA Certification
	Performance Evaluation
	State ID Card
	Tuberculosis Test

+ Add Additional Certification or Credential

Employment History:

Please provide your most recent positions of employment.

Employer:

Supervisor:

Phone Number:

Address 1:

Address 2:

City:

State:

Postal Code:

Date Employed:

To:

Employer:

Supervisor:

Phone Number:

Address 1:

Address 2:

City:

State:

Postal Code:

Date Employed:

To:

Employer:

Supervisor:

Phone Number:

Address 1:

Address 2:

City:

State:

Postal Code:

Date Employed:

To:

+ Add Additional Employer

Professional References:

Please provide professional references.

Name:

Phone Number:

Name:

Phone Number:

Name:

Phone Number:

+ Add Additional Reference

Additional Information:

What are your long-term dreams and aspirations? Please include both personal and professional goals.

Discuss any training or experience working with the elderly. How are you trained and/or experienced in working with the elderly?

What do YOU do that shows and proves you’re Reliable, Trustworthy and Honest? :

What would you like least about working with the elderly?

What hours are you available to work? We provide care 24 hours a day, 7 days a week.

Social Security Number:

Birth date:

Disclaimer:

CERTIFICATION AND RELEASE: I certify that I have read and understand the general requirements of Independent Care Contractors/Providers on page one of this form and that the answers given by me to the foregoing questions, and the statements made by me, are complete and true to the best of my knowledge and belief. I completely understand that I am submitting this Application as an interested Care Provider and that submission of the application is not a guarantee of employment. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in the rejection of my application. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any, and all, of my information including, but not limited to, work, criminal and credit history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information.

Signature:

Thank you for your interest in working for our agency.

Please submit the application below to be considered for a position as a caregiver.

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