Caregiver Application | WellSky Personal Care

Applicant Information:

First Name*:

Middle Name*:

No Middle 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

Professional References:

Please provide professional references.

Name:

Phone Number:

Name:

Phone Number:

Name:

Phone Number:

+ Add Additional Reference

Additional Information:

What are your long-term dreams and aspirations? Please include both personal and professional goals.

How did you hear about Home Helpers ?

Have you applied with Home Helpers before ?

Date you are available to start working ?

Have you ever worked for our company? if yes when:

When are you available to work ? Day Time Availability Evening Availability Overnight Shift Availability Weekend Availability Day Shift Only Availability Evenings Only Availability 24 Hour Availability Willing to accept Fill In / Temporary work:

Are you CPR & First Aid Certified? If YES, when does your certification expire?

Are you a US citizen or legally eligible to hold employment in USA? *If offered employment you may be required to provide documentation to verify employment eligibility. :

Have you ever been convicted of attempting or committing any crime other than a minor traffic violation? If YES, what was the date and provide some information about this A criminal conviction will not necessarily be a bar to consideration for employment. The disclosure of a misdemeanor conviction will not automatically result in disqualification. Upon hire, candidate will be sent for a fingerprint background check as required by law. Criminal Histories will be submitted to the National Crime Information Center (NCIC) for verification. Failure to disclose a conviction may be considered grounds for disqualification. :

Acceptable length of time to drive from your home to work?

Do you have valid Georgia CNA license?

Do you have a current TB test ?

Do you have a smart phone or device you receive emails and text messages on?

Do you have email and check it daily?

Have you ever had to leave a job, internship, or volunteer position due to injury sustained on the job?

Have you had any traffic violations in the past three (3) years? If YES to above please explain:

Do you have a valid drivers license, car insurance and reliable transportation ?

Please understand the office must have a copy of driver’s license, social security card, C.N.A. license or PCA certification, TB screen and First Aid and CPR certificate (within 60 days of hire.) prior to orientation and your first shift. You will be sent for a fingerprint background check as required by law. :

Other Skills, Background, Certifications or Experience related to the position applying for:

Have you had Workers Compensation Injuiries ? If Yes to above please explain.

Have you been arrested ? If yes to above please explain.

Have you been convicted of any crimes? If yes to above please explain:

Disclaimer:

I certify the information given is correct to the best of my knowledge and understand that falsification of this information is grounds for refusal to hire or, if hired, dismissal. I hereby authorize any of the persons or organizations listed in my application to give all information concerning my previous employment, education, or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application, and release all such parties from all liability that may result from furnishing such information to you. I authorize you to request and receive such information. In consideration for my employment and my being considered for employment by your company, I agree to adhere to the rules and regulations of the company and hereby acknowledge that these rules and regulations may be changed by your company at any time, at the company’s sole option and without any prior notice. In addition, I acknowledge that my employment may be terminated, and any offer of employment, if such is made, may be withdrawn, with or without prior notice, at any time, at the option of either the company or myself. I understand that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to assure or make some other personnel move, either prior to commencement of employment or to assure any benefits or terms and conditions of employment, or to make any agreement, that is contrary to the foregoing. I hereby acknowledge that I have been advised that this application will remain active for no more than 90 days from the date it was signed.

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.

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