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
	Annual Training and Evaluation
	CNA License
	CPR Certification
	Driver's License
	Driving History Report
	First Aid Certification
	Full PPE Don and Doff Test
	G-Tube Feeding Training
	Hoyer Lift
	In-Class Training: Alzheimers
	In-Class Training: Caregiver Basics and Skills Training
	LVN/LPN Certification
	N95 Fit Test
	Registered Nurse
	Skills Check-Off
	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:

Please give a brief description of your caregiving experience including how many years of professional caregiving experience.

What are your long-term personal and professional goals?

Why do you want to work for The Home Care Family?

What days of the week and hours of the day are you available to work?

Are you willing to work two weekends per month?

Do you own your method of transportation?

Have you been convicted of a crime (excluding misdemeanors and traffic offenses) and/or released from confinement following a conviction for any criminal offense within the past 10 years? If yes, please give a date, place, and nature of each such conviction.

Are you presently charged with any violation of the law other than traffic violation? If yes, please give a date, place, and nature of each such conviction.

Please list any additional alias's you have used. (e.g. maiden names):

Do you have any functional limitations that may affect your ability to perform the essential functions of this job, with or without reasonable accommodation? If yes, please list.

Disclaimer:

I certify that I have fully and accurately answered all questions and have given all information requested in this application for employment, and I understand that any wrong or incomplete information on the form may disqualify me for further consideration for employment or, if discovered after I am hired, may be grounds for my immediate dismissal. I understand that all such information is subject to verification by The Home Care Family, and hereby give my consent to The Home Care Family to investigate my background and qualifications using any means, sources, and outside investigators at its disposal. I agree to undergo any type of drug and/or alcohol testing, criminal background check and driving record check that The Home Care Family may require at any time. This is not an employment contract. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law.

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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