Caregiver Application | WellSky Personal Care

Thank you for your interest in working for our agency.

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

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:

Match Criteria:

Indicate caregiver's skills and limitations. These will be used for matching the caregiver with clients.

General

Able to Cook

Dementia Experience

Hospice Experience

Incontinence Experience

OK with Client Smoking

Transfers

Gait Belt Experience

Hoyer Lift Experience

Pets

OK with Cats

OK with Dogs

Max client weight for transfers:

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
	1st In-Service
	2nd In-Service
	3rd In-Service
	4th In-Service
	5 Hours Annual Trainings
	Application Form
	Arbitration Form
	Arbitration Form
	Car Insurance
	Chest X-Ray
	CNA License
	CPR Certification
	Criminal Record Statement (LIC508)
	Driver's License
	First Aid Certification
	Form 8850
	Form I-9
	Form W-4
	Handbook Receipt
	Health Insurance Waiver
	Health Insurance Waiver
	HHA Certification
	Home Care Aide Job Description
	Home Care Aide Registry
	Initial In Service / Training
	LiveScan / Finger Print (LIC9163)
	LVN/LPN Certification
	Offer Letter
	Performance Evaluation
	Requirement to Report Suspected Abuse SOC341A
	Tuberculosis Test
	Vehicle Insurance Card

+ 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.

Disclaimer:

I certify that the information contained in this application is correct to the best of my knowledge. I understand that to falsify information is grounds for refusing to hire me, or for discharge should I be hired. I authorize any person, organization or company listed on this application to furnish you any and all information concerning my previous employement, education and qualifications for employment. I also authorize you to request and receive such information. In consideration for my employment, I agree to abide by the rules and regulations, policy and procedures of the company, which rules/policy may be changed, withdrawn, added or interpreted at any time, at the company's sole option and without prior notice to me. I also acknowledge that my employment may be terminated, or any offer or acceptance of employment withdrawn, at any time, with or without cause, and with or without prior notice at the option of the company or my self.

Signature:

To what day do you want to copy this shift?

Date:

Please choose an ID, date range and payer for the new authorization.

New ID:

From*:

To*:

Paid By*:

Right Now Scheduled Time

Reason Code Message

Reason Code :

Action Taken :

I attest I have proper documentation to support this visit.