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
	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:

How were you referred to Preferred Care at Home?

Have you applied to us before?

Please provide two Emergency Contacts Names, Address, Phone Number and the relationship to you:

What days of the week are you available? Please select one or more from the following: Days, Evenings, Weekends, Live-in, Full-Time or Part-Time, .PLEASE be specific and accurate.

How many hours willing to work per week?

What date are you available to start working?

Are you available to work on short notice if called to fill in?

Are you eligible to work in US? :

Are you over the age of 18? :

Have you ever been convicted of/or plead guilty to a crime? If yes, please provide any details: date, location and charge:

Do you have a valid driver’s license? If yes, please provide State it was issued by and the Drivers License Number and exp date.

Have you ever been convicted of a moving violation(s) in the past 3 Years? If yes, please explain.

Do you have your own transportation?

Do you have current auto insurance?

Do you have a Level Two Back Ground Check through ACHA? This is required.

Do you have over 1 year of Home Health Care experience?

Are you working now? If so what days and hours?

Are you available for live in positions?

Can you work over nights?

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.

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