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:

Match Criteria:

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

General

Dementia Experience

Hospice Experience

Incontinence Experience

Insured Automobile

OK with Client Smoking

Transfers

Gait Belt Experience

Hoyer Lift Experience

Pets

OK with Cats

OK with Dogs

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
	30 Day Evaluation
	30 Day On Site
	6 Month On Site
	90 Day Evaluation
	Annual TB Screening
	Car Insurance
	Chest X-Ray
	Child Abuse Clearance
	CPR Certification
	Driver's License
	Federal Fingerprints
	PA State Criminal
	Passport
	Performance Evaluation
	Safety Cares
	School Age Children
	School On Site
	State ID Card
	Tuberculosis Test
	Yearly Evaluation

+ 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 many hours a week are you interested in?

Are you available to work weekends?

Minimum hourly pay rate?

Have you ever been convicted of a crime? If so, explain.

Explain why you are interested in providing services to people in need?

What type of position are you applying for? Direct Care Worker, Paraprofessional, or any.

Disclaimer:

I attest that all information provided within this application is true.

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.