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:

Education & Training:

High School

College

School:

Degree received:

Certifications and Credentials:

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

	Certificate	Mandatory Fields
	6 Month DCS Review
	90 Day Performance Review
	Basic Training Deadline (120 days)
	BCS Background Check- Expires 1 year and 10 months from last results letter.
	Car Insurance
	CNA License
	Continuing Ed
	CPR
	Drivers License
	Employment Authorization Card
	Finger Print Results Letter
	First Aid
	GED Certification
	HCA Certification
	Initial HCA Certification (200 days)
	N95 Fit Tested
	Nurse Delegation
	OPERATIONAL FILE AUDIT
	Performance Evaluation

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:

The first contact you will receive from us will be by text or email. What phone number or email address do you want to receive this contact on? NOTE: if you do not respond to this contact your application will be void.

Are you at least 18 years old?

Do you have a valid driver's license AND active car insurance?

Do you have written evidence that you are authorized to work in the United States? NOTE: you must provide this proof if you are offered this position.

Have you applied for a position with Home Care Services before? If "yes" when? And under what name?

Have you been employed by Home Care Services? If "yes" when? And under what name?

Have you ever been convicted of a crime? If "yes", list the crime(s), the degree, and the conviction date.

Have you ever been discharged from a job for making threats, fighting, or any other violent incidents?

Are you able to perform the essential functions of the job, with or without reasonable accommodations? If "no" then please explain.

How were you referred to us for this position? Please be specific.

Are you related to a current Home Care Services employee? If "yes" then please list their name and their relationship.

Please list the reason for separation from each prior employer you have listed on this application.

Have you served in the US military? If "yes" please provide which branch and dates of service.

May we contact the employers you listed in your application? If "no" please explain.

Date you are available to start work?

Preferred days of the week and hours you are available to work?

This position requires 70 hours of training, which are usually between 8:00 a.m. and 5:00 p.m. Monday through Friday. Will you be available for training during these times? Exemptions: Current Home Care Aides and CNA's.

Do you have a current Home Care Aide or CNA? If "yes" please list the credential number and expiration date.

In order for your application to be complete, you must provide TWO previous supervisors. Please include NAME, TITLE, and PHONE NUMBER.

Are you willing to work with clients that have pets (cats, dogs)?

Are you willing to work with clients that smoke?

Disclaimer:

I understand that this application is not a contract or offer of employment. I understand that documentation of employment eligibility for compliance with the U.S. Immigration Control and Reform Act is required at the time of hire. I hereby attest with my signature below that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize Senior Life Resources Northwest to verify their accuracy and to obtain reference information on my work performance. I hereby release Senior Life Resources from any and all liability of whatever kind and nature which, at any time, could result from obtaining and having an employment decision based on such information. I understand that, if employed, falsified statements of any kind or omissions of facts called for on this application shall be considered sufficient basis for dismissal. I understand that Senior Life Resources will be reviewing my driving record for the past 36 months. I understand that should an employment offer be extended to me and accepted that I will fully adhere to the policies, rules, regulations of employment of the employer. However, I further understand that neither the policies, rules, regulations, nor anything said during the interview process shall be deemed to constitute the terms of an implied employment contract. I understand that any employment offered by Senior Life Resources Northwest is for an indefinite duration. If I am applying for a HCP position, my employment will be governed by OPEIU Local 8 Bargaining Agreement.

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.

General

Certifications

Transfers

Pets