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*:

Mobile Phone*:

Email*:

Hours wanted weekly:

Date Of Birth:

Certifications and Credentials:

Please check all that apply and enter the details in corresponding mandatory fields.

	Certificate	Mandatory Fields
	Car Insurance
	Chest X-ray
	CMT License
	CNA License
	COVID-19 Vaccination
	CPR
	Drivers License
	Health Form (Annual Physical)
	LPN License
	Passport
	Passport Card
	PR/Green Card
	RN License
	Skills Lab (Annual)
	Social Security Card
	ID Card
	TB Questionnaire (Annual)
	Tuberculosis Test
	Work Authorization

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 CarePlus? Who referred you?

How many years of experience in caregiving do you have? Please share anything you would like us to know about your skills and experience.

How do you handle difficult clients?

What do you see yourself doing in 5 to 10 years?

What shifts are you available to work? Here are the options—please list ALL you are available for: SHORT SHIFTS: 7a-11a, 8a-12p, 9a-1p, 10a-2p, 12p-4p, 4p-8p LONGER SHIFTS: 7a-3p, 3p-11p, 11p-7a, 7a-7p, 7p-7a EXAMPLE: Weekdays 10a-2p, 4p-8p Weekends 3p-11p:

Disclaimer:

I certify that the information contained in this application is correct to the best of my knowledge. I understand that falsifying information is grounds for discharge should I be hired. I authorize any person, organization, or company listed on this application to furnish you any and all information concerning my previous employment and qualifications for employment. I also authorize you to request and receive such information. In consideration for employment, I agree to abide by the policies and procedures of the company. I understand that these may be changed at any time, at the company's discretion and without prior notice to me. I also acknowledge that my employment may be terminated, or any offer or acceptance of employment withdrawn, at any time, with or without cause, and with or without prior notice by the company or myself.

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.

Certifications

Transfers

Pets

Facility Approvals

Other/Misc