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:

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
	Car Insurance
	Chest X-Ray
	CNA License
	CPR Certification
	Driver's License
	First Aid Certification
	HHA Certification
	Influenza Vaccine/Flu shot
	LVN/LPN Certification
	Passport
	Performance Evaluation
	Registered Nurse
	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:

Are you over the age of 21?

Do you have home care experience?

What do you like most and what do you like least about being a caregiver?

Are you willing to assist a client with care for their pets?

Please let us know the days and hours you are available to work, please be specific.

What hourly rate are you looking for?

Do you have a vehicle and current insurance? Can you provide transportation?

Do you have previous experience working with clients with Alzheimers or other forms of dementia? Do You Have Any Special training? :

Are you able to cook a hot meal? Please provide an example of what you would make for lunch if you had everything you could possibly want in the pantry:

How did you hear about us?

How would one of your supervisors describe you? :

What sets you apart from other caregivers? :

Do you have a CLEAN background? Will anything come up on a local and national search?

Please tell us anything else you think we should know:

Disclaimer:

I HEREBY AUTHORIZE Living Well Senior Care, LLC TO REQUEST AND RECEIVE FROM ALL PRIOR EMPLOYERS WITHIN ONE YEAR OF THE DATE OF THIS APPLICATION, ANY AND ALL PERTINENT INFORMATION CONCERNING MY PRIOR EMPLOYMENT AND ITS TERMINATION, INCLUDING THE REASONS FOR SUCH TERMINATIONS. I hereby state that all of the foregoing information I have supplied in this application is a true and complete statement of the facts. False statements contained in this application are immediate cause for dismissal from registrant caregiver status. I further give my permission for this agency to verify all schooling and references.

Signature: