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:

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

Additional Information:

In a few brief sentences, please share with us why you would like to work with At Home Senior Care.

Please describe any training or experience you have had (personally or professionally) that applies to caring for the elderly:

Please describe your work or volunteer history over the past two years:

Please list which of the following services you are willing to provide and/or willing to be trained to provide: COMPANIONSHIP/SOCIAL ENGAGEMENT, MEAL PREPARTION, LAUNDRY, WALKING/STANDING ASSISTANCE, TRANSPORATION, PERSONAL CARE, RUNNING ERRANDS, HOSPICE CARE, HOMEMAKING :

Do you have reliable transportation to drive yourself to work?

Have you ever been convicted of a felony and/or misdemeanor? If so, please describe:

Do you have any pending criminal action(s) at this time?

Are you legally able to work in the United States?

Please list three PERSONAL References (Non-family member): Include Name, Phone Number & Relationship :

Please list three PROFESSIONAL References (Supervisors & recent co-workers) Include Name, Phone Number & Relationship:

Disclaimer:

I understand the following: AT HOME SENIOR CARE is an equal opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, gender, sexual orientation, marital status, national origin, citizenship, age or disability. We assure you that your opportunity for employment with At Home Senior Care or its agent to verify any of the information including but not limited to criminal background and motor vehicle driving reports and release all persons supplying such information from liability for damages for issuing this information. I certify that the above information given in this application is true and correct to the best of my knowledge, and I have withheld nothing that if disclosed would affect this application unfavorably. I understand that any false information or omission is cause for the employment process to be terminated or immediate discharge if employed. I understand that employment with At Home Senior Care is per diem, as needed and may be intermittent.

Signature: