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 expiration date and any notes as applicable.

Active	Type	Expiration Date	Notes
	Car Insurance
	Chest X-Ray
	CNA License
	Covid Booster completed
	Covid Shots Done
	CPR Certification
	Driver's License
	First Aid Certification
	Flu completed
	Hep B completed
	HHA Certification
	LVN/LPN Certification
	MMR completed
	Passport
	PCA completed
	Performance Evaluation
	Registered Nurse
	State ID Card
	Supervisory Visit Due
	Tdap completed
	Tuberculosis Test
	Varicella completed

+ 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:

Are you legally eligible to work in the United States?

Please provide your availability:

Do you have a car with insurance and can provide a copy of your registration and insurance ID card? :

Are you willing to transport clients in your vehicle if necessary?

Are you able to perform the essential functions of the job for which you are applying, with or without reasonable accommodations? If no, describe the functions that cannot be performed: :

Disclaimer:

I understand that all applicants considered for hire will be subject to a thorough background screening process that includes a criminal background check, and may include a credit check, motor vehicle check and drug screen. (Please note that ALL positions require you to be insured and bonded.) I certify that the facts contained in this application and/or interview(s) are true and complete. Any misrepresentation or falsification of information or significant omissions will be cause for rejection of my application or for subsequent discipline up to and including my dismissal from employment if discovered at a later date. I understand that, if employed, my employment is not guaranteed for any term, and my employment may be terminated by the employer or myself at any time and for any reason with or without prior notice. No representative of Comfort Keepers other than the owner(s) is authorized to make any assurance or promise of continued employment and any such assurance must be in writing signed by the owner(s). The employer, Comfort Keepers, is an Equal Opportunity Employer. The employer does not discriminate in employment and no questions on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state, or federal law. By clicking submit I certify that I have read the above and understand the statements.

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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