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:

Match Criteria:

Indicate caregiver's skills and limitations. These will be used for matching the caregiver with clients.

Max client weight for transfers:

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
	APS Registry Search
	Background Check
	Car Insurance
	CEU's
	CNA License
	CPR Certification
	Criminal Attestation
	Direct Care Worker
	Driver's License
	Drug Screen
	First Aid Certification
	Level 1 - Fingerprint Clearance Card
	LVN/LPN Certification
	Passport
	Performance Evaluation
	Registered Nurse
	State ID Card

+ 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 did you hear about Caring Presence?

In your opinion, tell me what makes you a good caregiver [or why you think you will be a good caregiver].

What do you like most about working with the elderly, disabled, or convalescing client?

What do you find most rewarding about being a caregiver?

What do you find most challenging in this type of work?

What are three positive things your past clients would say about you?

Are you comfortable performing care/hygiene tasks for an elderly client?

Disclaimer:

Authorization to Release Information “I hereby certify that the facts contained in this application are true and complete to the best of my knowledge and I understand that if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein, the references and employers listed above to give Caring Presence (“the Company”) any and all information concerning my employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. I also understand and agree that no representative of the Company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized representative of the Company. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.”

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.