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:

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
	BCI/FBI Background Check
	Car Insurance
	Driver's License
	Health Ins (FT/FTE)
	LVN/LPN Certification
	Onboarding Training
	Performance Evaluation
	Registered Nurse
	STNA Certification

+ 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 here about Home Helpers - Lancaster? (Please be specific - Indeed, Facebook, Classified Ad, Newspaper, Radio, Friend, Home Helpers Employee (name), other, etc.):

The 11 questions following are **REQUIRED** to be answered: Briefly, what are your long-term dreams and aspirations? Please include both personal and professional goals.

In your own words, define "Caregiver".

What is your "WHY" for applying with our company?

What do you bring to the position that you believe will make you an EXCEPTIONAL CAREGIVER?

Are you willing to submit to pre-employment background checks and drug screening?

o you possess a current VALID driver's license, current Automobile Insurance, a safe/reliable vehicle, and the ability to drive yourself to/from work?

With regard to the # of hours you would like to work, please list here what your AVAILABLE HOURS are to work each day? Please list each day with the times you are available to work each day. (ie. Su 12am-7am, M 8am-9pm, Tu not available, W 5pm-1159pm, etc):

Employment verification is a necessary part of the hiring process. Are we authorized by you to contact the above mentioned employers (Current/past)?? If you prefer we not contact a listed employer, please indicate who and why:

Have you ever applied to or been employed previously by this company? If yes, please provide appropriate dates.

What is your expectation of an hourly pay rate, if offered employment with our Company??

Disclaimer:

I hereby certify that the information contained in this employment application I submit to Home Helpers (Compassionate Caregivers LLC, dba..., here forward called Home Helpers) is true and complete to the best of my knowledge. I understand that material omissions or falsification of this application in any detail may result in my disqualification from consideration for employment or for dismissal from employment. I also understand that my employment is subject to a satisfactory check of references, clearance of criminal background checks, and required drug screening. I give Home Helpers the right to investigate the information given and to secure additional information if necessary. I authorize my previous employers, educational institutions and all other individuals and organizations listed in this application form to give information about my employment, work habits and character. I agree that Home Helpers and my previous employers, educational institutions and all other individuals and organizations listed in this application will not be held liable in any respect if an employment offer is not made, is withdrawn, or my employment is terminated because of misrepresentations or omission of requested information. I understand that upon offer and acceptance of a position with Home Helpers I will be required to immediately furnish documentation establishing my identity and eligibility to be legally employed in the United States. I understand that Compassionate Caregivers LLC (dba Home Helpers) is in no way obligated to provide employment and also that I am in no way obligated to accept employment, if offered. This application does not bind either party, and the statements contained herein do not constitute and should not be interpreted to constitute any sort of contract of employment for a specific period of time.

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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