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
	2- Step PPD
	Annual PPD
	Car Insurance
	CNA License
	Driver's License
	Drug Test
	First Aid Certification
	Health Assessment
	Performance Evaluation
	SLED

+ 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:

Emergency Contact Information: 1. Name 2. Relationship 3. Phone (cell) 4. Phone (home):

Position & Availability: 1. What position are you applying for? 2. Are you looking for part-time work or full time? 3. What is you hourly wage requirement? 4. Do you have the legal right to work in the US? 5. Are you eligible to work in the US? :

Who else do you know that would make a good canidate for Visiting Angels? Please include their full name and phone number so we can contact them!

What do you enjoy most about working with the elderly? :

What do you like the least about working with the elderly? :

Do you speak any other languages in addition to English? :

How did you hear about Visiting Angels? (Google, Facebook, Word of Mouth, Current Employee, Magazine Ad...):

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

Discuss a specific accomplishment you've achieved in a previous position that indicates you will thrive in this position:

Why have you chosen to apply for Visiting Angels?

Disclaimer:

I hereby authorize the above-named individual, company, or institution (the “Employer”) to provide any and all information and opinion concerning my employment and/or my separation from employment with the Employer, upon request, to Visiting Angels. I agree that the information and opinion which I authorize the Employer to provide may include, but is not limited to, performance evaluations, disciplinary warnings and actions, reasons for separation from employment, and information and opinions about my conduct, performance, attendance, or any other aspect of my reputation or character, which may be positive or negative. I agree to hold the Employer (including its principals, employees, agents, consultants, attorneys and insurers) harmless and free of any and all claims or causes of action arising from any such provision of information and opinion, no matter what its character.

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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