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:

Match Criteria:

Indicate caregiver's skills and limitations. These will be used for matching the caregiver with clients.

General

Dementia Experience

Hospice Experience

Incontinence Experience

Insured Automobile

OK with Client Smoking

Transfers

Gait Belt Experience

Hoyer Lift Experience

Pets

OK with Cats

OK with Dogs

Max client weight for transfers:

Education & Training:

High School

College

School:

Degree received:

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 hear about Changes Home Care?

As a condition of employment all employees must be "Bondable" & "Insurable". Are you at least 18 years of age?

Are you willing to provide service to a client with a cat?

Are you willing to provide service to a client with a dog?

Are you willing to provide service to a client that smokes?

Are you willing to drive 20-25 miles to get to a client’s home?

Applicants that are considered for hire will be subject to a thorough background screening process that includes a criminal background check, motor vehicle, sex offender and drug screen. Are you willing for our agency to conduct your background checks?

Have you had any moving traffic violations in the past 3 years? If yes, please describe: :

Are you authorized to work in the U.S.? :

Are you a U.S. citizen? If you are not a U.S. citizen, please indicate VISA type and number. :

Do you have a valid Indiana Driver's License?

Do you have current auto insurance?

Do you have reliable transportation?

Have you ever been employed at Changes Home Care?

Name one thing that you liked about your previous job.

What was the hardest thing about your previous job?

Name one thing you disliked about your previous job.

Why did you choose Changes Home Care?

Disclaimer:

Changes Home Care is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, marital status, national origin, disability or handicap, or veteran status. APPLICANT'S CERTIFICATION AND AGREEMENT I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize Changes Home Care to verify their accuracy and to obtain reference information on my work performance. I hereby release Changes Home Care from any/all liability of whatever kind and nature which, at any time, could result from obtaining and having an employment decision based on such information. I understand that, if employed, falsified statements of any kind or omissions of facts called for on this application shall be considered sufficient basis for dismissal. I understand that should an employment offer be extended to me and accepted that I will fully adhere to the policies, rules and regulations of employment of the Employer. However, I further understand that neither the policies, rules, regulations of employment or anything said during the interview process shall be deemed to constitute the terms of an implied employment contract. I understand that any employment offered is for an indefinite duration and at will and that either I or the Employer may terminate my employment at any time with or without notice or cause. Signature of Applicant

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.

General

Transfers

Pets