Caregiver Application | WellSky Personal Care

Applicant Information:

First Name*:

Middle Name*:

No Middle Name:

Last Name*:

Address*:

Address Line 2:

City*:

State*:

Postal Code*:

Home Phone*:

Mobile Phone*:

Email*:

Location:

Hours wanted weekly:

Date Of Birth:

Match Criteria:

Indicate caregiver's skills and limitations. These will be used for matching the caregiver with clients.

General

Dementia Experience

Incontinence Experience

Insured Automobile

Transfers

Gait Belt Experience

Hoyer Lift Experience

Pets

OK with Cats

OK with Dogs

Max client weight for transfers:

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
	Annual Flu Vaccination Shot
	Car Insurance
	CMT Certification
	CNA License
	COVID-19 Vaccination
	CPR Certification
	Driver's License
	First Aid Certification
	HHA Certification
	LVN/LPN Certification
	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 did you hear about the Agency / Job?

Please briefly outline your caregiving experience:

Specific your availability: Days, Evenings, Weekends, Live-ins, and number of hours requested:

Caregivers are always being evaluated for hire - will you consider being evaluated for other positions the Agency may have a need for?

Maryland Minimum Wage is $13.25 per hour - what is the lowest Per Hour you wage will accept? :

Live-in (or extended shifts) are paid daily for 16 hrs duty for every 24 hrs, plus boarding accommodations while working - what is the lowest daily wage you will accept?

Date you can start working shifts?

Do you have reliable transportation to get back and forth to work?

Are you willing to undergo a background check, in accordance with federal, state, and local law/regulations? :

Are you willing to comply with the Agency's health guidelines, including recommended vaccines?

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

Have you accessed and submitted the (required) Skills Assessment and OnBoarding Questionnaires?

When is the best time for us to contact you to schedule your interviews? :

Disclaimer:

Immigration Act I understand that, if hired, I will be required to offer examination documents proving that I am a United States citizen or an alien currently authorized to work in the United States. I also understand that my continued employment is contingent upon my proving the necessary documentation within the prescribed time frames. READ CAREFULLY BEFORE SUBMITTING I hereby certify, to the best of my knowledge that the answers give are true and complete. I also understand that an omission or falsification may disqualify me from consideration for employment or may be grounds for my immediate dismissal if hired. I agree to conform to the rules and regulations of the company and, if employed, I understand and agree that my employment is at-will and that no employment contract rights have been created. I also understand and agree that my employment may be terminated at any time with or without cause, and with or without advance notice at the option of either the company or myself. I understand that no supervisor, manager, or other representative of the company has any authority to enter into any express or implied contract for employment for any specific period of time. Any agreement contract to the above must be in writing and expressly state that is a contract and be signed by the authorized representative of the company. I understand that employment, for certain positions, and is conditional upon successful completion of a substance abuse screening test as part of the company’s pre-employment policy. We appreciate the interest of all applicants; however only those selected for an interview will be contacted.

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.

General

Transfers

Pets