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
	CaregiverList Renewal Annual
	1st Training Caregiver List
	Car Insurance
	Chest X-Ray
	CNA License
	CPR Certification
	Driver's License
	Performance Evaluation
	Retention - 1wk call
	Retention- 28day eval/visit/careheroes
	Retention- 2wk call?
	Retention- 60 day
	Retention- 6wk
	Retention- 90 dayeval
	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

Additional Information:

Are you over the age of 18 and legally authorized to work in the United States:

Have you been sanctioned, cited, reported or excluded from participation in Medicare, Medicaid, or any other healthcare related law or regulation? (if yes, please explain) If you answered “Yes” you will not be automatically disqualified from employment consideration, except as required by state or federal law. Have you ever been convicted of a crime other than a minor traffic violation? (If yes, please explain) If you answered “Yes” you will not be automatically disqualified from employment consideration, except as required by state or federal law. Have you been involved in the substantiated abuse or neglect of children or adults under the laws of this or any other state of the United States? (If yes, please explain) If you answered “Yes” you will not be automatically disqualified from employment consideration, except as required by state or federal law.

Have you attended either a certified caregiver, CNA or other formalized training program for this type of work?

What is your current availability? What shifts do you want to work specify days/times :

Can you transport clients in your car or their car?

Do you have experience with a personal care wiping clients, changing diapers showering. Describe what you've done and how hard the client was OR would you like more training with these skills:

Do you have experience with a transfer device for example hoyer lift or sit /stand, OR do you need some more training to do this? :

Thank you for your interest in working for our agency.

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

General

Transfers

Pets

Other/Misc