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:

Certifications and Credentials:

Please check all that apply, and enter the expiration date and any notes as applicable.

Active	Type	Expiration Date	Notes
	1 LNA, Current
	2 LNA or CNA Expired
	3 HHA or PCA Certificate
	Attended Orientation
	Badge
	Car Insurance
	CPR Certification
	Driver's License
	Final COVID 19 Vaccine
	First Aid Certification
	Flu Shot Date
	LVN/LPN Certification
	National Background Check
	Registered Nurse
	State ID Card
	Tuberculosis Test

+ 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 many years of professional experience do you have caring for seniors. If none, have you run a household or cared for elderly or disabled family members.

Tell us about your care-giving experience and the kinds of care you have given.

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

If I have not filled out the work experience in this application I have either submitted a resume or applied to this position through through Indeed and included my work experience. All information is accurate as a condition of employment. Initial Here.

Disclaimer:

By submitting this application I agree that all information here is true and that any incorrect information is grounds for immediate dismissal. I also agree that I accept Visiting Angels right to do business and that I will not enter into any commercial relationship with any client or other person to whom Visiting Angels introduces me. I understand and agree to submit to criminal background checks at any time during employment and to random checks for illegal use of drugs or use of alcohol to be under it's influence during working hours.

Signature: