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
	Automobile Registration
	CA Harassment Preventn Training
	CA Workplace Violence Training
	Car Insurance
	Chest X-Ray
	CNA License
	Dementia Training
	Driver's License
	First Aid Certification
	HCA Annual State Training
	HCA State Registration
	Introduction to GEMS
	Passport
	Sapphire 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

Additional Information:

What experience do you have as a caregiver?

Would you be able to pass a LIFETIME criminal background check?

What is your desired hourly wage range?

Do you have a valid California driver license and car insurance?

Do you have your own reliable transportation?

Is your mailing address different from your physical address?

IMPORTANT: YOUR ANSWER BELOW IS REQUIRED TO PROCESS THIS APPLICATION!! By typing "YES' in the box below, I agree to the following terms and conditions of this application: I CERTIFY that the information contained in this application is correct to the best of my knowledge, and I understand that any misstatement or omission of information is grounds for ending the hiring process or dismissal from employment. I authorize verification of information provided on this application; and authorize the references listed above to give Senior Helpers of SLO County all pertinent information concerning my previous employment; and release all parties from all liability for any damage that may result from furnishing the same to Senior Helpers of SLO County. I further agree that either I or Senior Helpers of SLO County may terminate my employment with or without cause and with or without prior notice, at any time. No representative of Senior Helpers other than an executive officer has the authority to enter into any agreement for employment for any specified period of time. I understand that I may be required to submit to a drug test in accordance with Senior Helpers of SLO County drug testing policy.

Disclaimer:

SENIOR HELPERS of SLO County is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, gender identity/expression, national origin, citizenship, military/veteran status, age, medical condition, or disability. We assure you that your opportunity for employment with us depends solely on your qualifications.

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.