Caregiver Application | WellSky Personal Care

Thank you for your interest in working for our agency.

Please submit the application below to be considered for a position as a caregiver.

Applicant Information:

First Name*:

Middle Name*:

No Middle Name:

Preferred Name:

Last Name*:

Address*:

Address Line 2:

City*:

State:

Postal Code*:

Mobile Phone*:

Email*:

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
	Active PIP
	Annual Performance Evaluation
	Annual TB Risk Assessment
	Background Check
	Benefits Offered
	Birthday
	Car Insurance
	CEUs (Annual)
	Chest X-Ray
	CNA due 365 days from DOH
	CNA License
	CPR Certification
	Dementia Training
	Driver's License
	Employment Authorization Card
	First Aid Certification
	Food Handler's Permit
	HCA Certification
	HCA due 365 days from DOH
	HIV/AIDS Certification
	HR Check-in
	Mental Health Training
	NAR Certification
	Nurse Delegation Certificate
	Nurse Delegation Certificate with Diabetes Specialty
	Orientation & Safety
	Passport
	Performance Evaluation
	Permanent Residency Card
	PTO Use
	Scheduling Check-in
	Sick & Safe
	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:

Which job posting are you responding to?

Which days are you available to work? Please specify days (Sat, S, M, T, W, Th, F), times, and if you like overnights or 24 hour (live-in) shifts. ESPECIALLY TELL US IF YOU WILL WORK WEEKENDS.

Why do you think you would be a good addition to Husky Senior Care?

How many total years of caregiving experience do you have?

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

What kind of caregiving credential do you have (NAR, HCA, NAC/CNA, etc)? :

This job requires travel. Do you own a reliable car or have reliable transportation?

This job requires a person to lift approximately 50 pounds on a semi-regular basis. Are you physically able to perform the duties of this job?

TO CHECK ON THE STATUS OF YOUR APPLICATION, OR TO ASK QUESTIONS, PLEASE CALL OUR HUMAN RESOURCE AT 425-440-1134. THANK YOU!

Disclaimer:

By signing below, I pledge that the above information is true and accurate and acknowledge that any false statements are grounds for dismissal. I authorize Husky Senior Care and Longhouse to call the above references and I authorize all references listed above to release information about me to Husky Senior Care. I hold references harmless for anything that they say about me while providing an employment reference to Husky Senior Care.

Signature:

To what day do you want to copy this shift?

Date:

Please choose an ID, date range and payer for the new authorization.

New ID:

From*:

To*:

Paid By*:

Right Now Scheduled Time

Reason Code Message

Reason Code :

Action Taken :

I attest I have proper documentation to support this visit.

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