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
	401k opt out form
	Acceptance of Employment
	Annual TB Questionnaire-chest-xray receipients
	Background Check
	Car Insurance
	Car Registration
	Caregiver Application
	Chest X-Ray
	CHHA added to roster site
	CHHA Skills Check by Nurse
	CHHA State Verification Report
	Competency Test
	Confidentiality Agreement
	Coronavirus Training
	Coronavirus Vaccination
	CPR Certification
	Direct Deposit
	Driver's License
	Fraud, Ethics, Compliance
	Health Attestation-Annual
	HEP Declination
	HHA Certification
	I-9
	Interview Summary Form
	Job Description
	MMR Vaccines
	Orientation Form
	Passport
	Performance Evaluation
	Permanent Resident Card
	Photo Badge
	Physical Exam
	References - Personal
	References - work
	Sexual Harassment Policy
	SSN Card
	State ID Card
	Training : COVID-19
	Tuberculosis Test
	W-4
	Work Auth. Card

+ 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 was your reason for leaving prior employment - specify reason for each employment period.

Date of Birth:

What is your Social Security Number?

Are you a US Citizen?

If you are not a US Citizen, are you authorized to work in the United States? Provide your permanent resident card ID number. :

Position you are applying for - Mature Companion, Certified Home Health Aide, Certified Nurse Assistant:

NJ CHHA License Number:

Expiration date:

Issuing State of License:

Do you have a vehicle?

Drivers License Number :

How far are you willing to travel?

I hereby authorize Seniors Helping Seniors to request and receive from all prior employers within one year of the date of this application, any and all pertinent information concerning my prior employment and its termination, including the reasons for such termination.

Are you covid vaccinated?

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.

General

Transfers

Pets