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
	Annual Caregiver U Training
	Annual Skills CNA Verification
	Bloodborne Pathogens
	Car Insurance
	Care Provider Plus
	CNA License
	COVID-19 Vaccine
	CPR Certification
	Criminal Background Check
	Driver's License
	Employee Handbook Acknowledgement
	First Aid Certification
	LVN/LPN Certification
	Nurses Aide Certification
	Passport
	Performance Evaluation
	Professional Boundaries Training
	Q1 Training
	Q2 Training
	Q2 Training
	Q3 Training
	Registered Nurse
	State ID Card
	Teepa Snow In Person Training
	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 provide any alias names (e.g., maiden name) that you may have used in the last 5 years.

Are you a US citizen?

Have you been at your current address at least 5 years? If not, please provide previous address(es) that you have lived at for the last 5 years.

Do you have any specialized training such as vocational training in the health care field or specialized certifications or licenses in the medical field? :

How did you hear about Seniors Helping Seniors?

The Seniors Helping Seniors concept is based on mature persons helping our Seniors. We define "mature" as at least 50 years old. Do you meet this requirement?

Why do you want to work for Seniors Helping Seniors?

What hobbies and favorite activities do you do for fun? Have you done any volunteer work?

Do you have any physical restrictions or limitations?

Ideally, how many hours per week would you like to work?

What days of the week are you AVAILABLE (from Monday to Sunday)? Please also list times (out of a 24 hour day) you would consider yourself available.

If hired, do you have reliable transportation? If so, what is it?

Please provide the name, relationship to you, and phone number for one or more persons that we may contact in case of an emergency.

Please identify your availability for a follow-up phone call.

Disclaimer:

"I certify that the facts contained in this application are true, accurate and complete to the best of my knowledge; and I understand that, if hired, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above to give you any and all information they may have, personal or otherwise, and release all parties from all liability for damage that may result from furnishing same to you."

Signature: