Caregiver Application | WellSky Personal Care

Applicant Information:

First Name*:

Middle Name*:

No Middle Name:

Preferred Name:

Last Name*:

Address*:

City*:

State*:

Postal Code*:

Home Phone*:

Mobile Phone*:

Email*:

Location:

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
	Caregiver Training
	Caregiving Training For Vi At La Jolla Village
	Chest X-Ray
	CNA License
	COVID 2nd Booster Shot
	COVID 3rd Booster Shot
	COVID Bivalent Booster Shot
	COVID Booster Eligibility
	COVID Booster Shot
	COVID Vaccinated (Fully)
	CPR Certification
	Driver's License
	First Aid Certification
	HCA CDSS Registry
	HHA Certification
	LVN/LPN Certification
	MA Certification
	Sexual Harassment Training
	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 is your Social Security Number(SSN)?

What is your Home Care Aide (HCA) CDSS registry number?

This job may require you to assist our clients with transfers from/to a bed, commode, couch, wheelchair, etc. Are you able to perform this task? YES or NO?

How did you hear about us?

Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation? If no, describe the functions that cannot be performed.

Are you currently employed?

What were your reasons for leaving your previous employers?

Past Employment: We may be contacting the employers and references listed above. If there are particular employers you do not wish us to contact, please list their name below.

I verify that I am at least 18 years of age. YES or NO?

List the following items in the order of importance to you when accepting a job offer: 1.Client's Location 2.Wage 3.Schedule:

Please list your job title and duties for each employer listed on this application.

Expected Hourly Wage?

Optional: Many of our clients do not speak English. Do you speak, write or understand any foreign languages? If yes, which language(s)?

Indicate if ever employed under a different name and list all names used for employment.

Do you have a valid driver license and an insured vehicle to transport clients?

Disclosure Statement: All Heart Home Care is an equal-opportunity employer and is committed to providing a workplace free from harassment or discrimination. All employment decisions are made without regard to race, color, religion, gender, national origin, ancestry, sex, age, handicap, marital status, sexual orientation, physical or mental disability, pregnancy, military status, or any other basis prohibited by law. IMPORTANT: All caregiver positions at All Heart Home Care are considered Temporary (seasonal) due to our senior client's weakened and/or medical conditions. Continued employment is not guaranteed for any caregiver as all employment is at-will, indefinite and not for any specific period of time. By TYPING YOUR NAME BELOW, you agree to use your electronic signature and hereby understand and accept this condition of employment should you be hired:

Please PRINT YOUR NAME below acknowledging you have read and understand the following: I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery. I hereby authorize All Heart Home Care to thoroughly investigate my references, work record, education and other matters related to my suitability for employment (excluding criminal background information) unless otherwise specified above. I further authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure. I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the Company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the Company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the Company's designated representative. In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire. The Company will consider qualified applicants, including those with criminal histories, in a manner consistent with state and local "Fair Chance" laws. By TYPING YOUR NAME BELOW, you agree to use your electronic signature and hereby understand and accept this section:

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

Other/Misc