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:

Classification:

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 expiration date and any notes as applicable.

Active	Type	Expiration Date	Notes
	Car Insurance
	Caregiver Development Program
	Chest X-Ray
	CNA License
	Covid-19 Vaccine
	Covid-19 Weekly Testing
	Driver's License
	Employment Authorization Card
	Flu Vaccine
	HCA Hire Date
	HCA Inital Reg/Pers ID#
	HCA Initial Training
	HCA Next Training Final Due Date
	HCA Reg Renewal
	HCA Rehire Date
	HCA Year 01 Training
	HCA Year 02 Training
	HCA Year 03 Training
	HCA Year 04 Training
	HCA Year 05 Training
	HCA Year 06 Training
	HCA Year 07 Training
	HCA Year 08 Training
	HCA Year 09 Training
	HCA Year 10 Training
	HCA Year 11 Training
	HCA Year 12 Training
	HCA Year 13 Training
	HCA Year 14 Training
	HCA Year 15 Training
	Passport
	Performance Evaluation
	Scrubs
	Special Training
	State ID Card
	Tuberculosis Test
	Visiting Angels Success Training

+ 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 did you hear about employment opportunities with Visiting Angels?

How many years of experience do you have as a caregiver?

Have you ever worked for a Homecare Agency? If yes, please list the name of each agency.

What days are you available to work?

What hours are you available to work?

Are you available to work in emergency fill-in situations?

Are you available to work holidays?

Are you available to do overnight shifts? If so, are you able to do overnights that are awake shifts?

If available for overnight shifts, how many per week?

Do you have anything to add about your availability?

What is your desired hourly wage?

Do you have a valid driver's license and reliable/insured vehicle? Please know that these are both required for this position. :

Are you willing to use your car to transport clients?

Do you have any special skills?

What language(s) do you speak?

What language(s) do you read/write?

Describe your caregiving experience?

Describe any experience with Alzheimer's Disease/Dementia.

Describe any experience with developmentally disabled individuals.

Describe any type of training you may have that would qualify you to work with our clients.

Are you at least 18 years of age?

Can you, after employment, submit verification of your legal right to work in the United States?

Are you willing to submit to a drug screening?

Based on the employment references listed above, please describe your duties, particularly those that relate to caregiving.

Emergency Contacts: Name/Relationship/Phone Please include two.

I certify that information contained in this application is true and complete. I understand that false information, omission, or misrepresentation may be grounds for not hiring me or for termination of my employment at any point in the future if I am hired. I authorize the verification of any information listed above.

To be signed and dated during initial interview. Signature:__________________________________________________ Date: _____________________________________________________:

Disclaimer:

I certify that all answers given by me are true, accurate, and complete to the best of my knowledge. I understand that falsification, misrepresentation, or omission of facts on this application (or any other accompanying or required documents) or during the application process will be cause for denial of employment or immediate termination of employment, regardless of when or how discovered.

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.

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