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
	BG Check
	Car Insurance
	Chest X-Ray
	CNA License
	COVID-19 Vaccine
	CPR Certification
	Driver's License
	First Aid Certification
	Performance Evaluation
	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:

What are your employment goals and why are you interested in Care-Giving?

Are you 18 years or older? Please provide your Date of Birth and Social Security number. :

How do you handle patients that are characteristically upset and/or difficult?

Tell us about your experience as an in-home aide - How long have you been providing care, previous work situations, etc. Have you ever worked for us before?

Are you willing to perform household chores such as cooking or light housekeeping?

What do you like and dislike about home care?

Imagine that you shift ends at 2PM and your replacement hasn't arrived by 215 PM. How would you handle this? :

What are your expectations if hired? What are your desired hours?

What areas would you be willing to work? Collierville, Eads, Arlington, Oakland, Bartlett, Millington, Germantown, Downtown, North Mississippi, Senatobia. :

Are you willing to drive clients in your vehicle?

Have you ever been convicted of a crime? If so, provide details. This company will not deny employment to any applicant solely because the person has been convicted of a crime. The company, may, however, consider the nature, date, and circumstances of the offense as well as whether the offense is relevant to the duties of the position applied for.

Are you legally authorized to work in the US? Proof of authorization will be required upon employment. :

Do you have any physical limitations? If so please describe them.

Disclaimer:

• CRIMINAL BACKGROUND CHECKS - Criminal background checks are a mandatory part of our hiring process. As part of your application for employment, you will be asked a question about convictions for crimes. If you answer this question “yes”, you will be asked to provide details. A “yes” answer does not automatically disqualify you from employment. Failure to provide accurate information may affect your employment status. • DRUG USE POLICY - SENIOR CARE MANAGEMENT SOLUTIONS, INC. does not hire or knowingly employ persons who use illegal drugs. Persons employed by SENIOR CARE MANAGEMENT SOLUTIONS, INC. may be subject to periodic tests for illegal drugs. By completing this application, you are agreeing that upon request, you will provide a urine specimen or swab at the collection site designated by SENIOR CARE MANAGEMENT SOLUTIONS, INC., and to have the specimens tested at a laboratory selected by SENIOR CARE MANAGEMENT SOLUTIONS, INC. • SENIOR CARE MANAGEMENT SOLUTIONS, INC. does not discriminate in hiring or employment on the basis of race, color, sex, religion, disability, national origin, or on the basis of age. No question on this application is intended to secure information to be used for such discrimination. Proof of identity and work authorization will be required upon employment in accordance with federal regulations. This company intends to check and hold you responsible for the accuracy of the statements you make on this application. This application will receive consideration for six (6) months. A new application must be submitted after that.

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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