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
	Car Insurance
	Chest X-Ray
	CNA License
	CPR Certification
	Driver's License
	First Aid Certification
	HHA Certification
	LVN/LPN Certification
	Passport
	Performance Evaluation
	Permanent Resident
	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 long-term dreams and aspirations? Please include both personal and professional goals.

Name 3 qualities that best describe you.

Please explain how you would handle a difficult client?

Please explain why you chose to become a caregiver?

What is your availability? Are you available for Live-In, Weekend or Overnight shifts? Please provide the days and hours you are available to work.

What do YOU do that shows and proves you are reliable, trustworthy, and honest?

What do you like least about working with the elderly?

How are you trained and/or experienced in working with the elderly? Please discuss any training or experience working with the elderly.

Do you have dependable transportation?

Why do you feel you would be an excellent addition to the Solace Care team?

Are you currently employed / providing care to others? If yes, please explain.

Do you have experience with Advanced or Specialized Conditions (e.g. Dementia, Alzheimer's, Cancer, Parkinson's, Hospice, MS)? Please explain.

Can you be called at the last minute in case of emergency?

How did you hear about Solace Care?

Disclaimer:

By filing out this application and questionnaire, you are applying for employment at Solace Care. Solace Care is dedicated to a policy of non-discrimination of applications on any basis including race, color, age, sex, religion, disability, medical condition, national origin, or marital status. CERTIFICATION AND RELEASE: I certify that I have read and understand the general requirements of Solace Care on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I completely understand that I am submitting this Application for employment and that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application and/or employment if hired. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any information including, but not limited to, work, criminal and credit history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information.

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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