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*:

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
	6- Month Performance Evaluation
	Annual Checkr Background Check
	Annual Competency Checklist with ANE training
	Annual Evaluation
	Car Insurance
	Chest X-Ray
	Driver's License
	Health Assessment by Licensed Personnel (every 2 years)
	Passport
	Self-Reported Health History(every 2 years)
	State ID Card
	Supervisory Visit (every 90 days)
	TB Education & Questionnaire (yearly)
	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 days and hours are you available to work for Comfort Keepers? (Be specific and availability must be honored for at least 3 months):

What areas/cities are you available to work in? :

How many hours per week are you looking to work?

Please explain your professional and/or family caregiving experience:

Have you previously worked at Comfort Keepers?

Are you able to pass a health screening and drug testing?

Are you legally eligible to work in the United States? (Proof of eligibility is required.):

How did you hear about Comfort Keepers?

Type your name to acknowledge the following: I understand that my employment is contingent on the successful completion of a background check and DMV check. I authorize Comfort Keepers to verify my personal and/or professional references as listed in my application: :

By typing your name into the space below you agree to the following statements: 1) I certify that the facts contained in this application and/or interview(s) are true and complete. Any misrepresentation or falsification of information or significant omissions will be cause for rejection of my application or for subsequent discipline up to and including my dismissal from employment if discovered at a later date. 2)At will employment: I understand that, if employed, my employment is not guaranteed for any term, and my employment may be terminated by the employer or myself at any time and for any reason with or without prior notice. No representative of Comfort Keepers other than the owner(s) is authorized to make any assurance or promise of continued employment and any such assurance must be in writing signed by the owner(s). 3) The employer, Comfort Keepers, is an Equal Opportunity Employer. The employer does not discriminate in employment and no questions on this application is used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, state, or federal law. 4) I understand that the company may require pre-employment drug testing and may require drug testing due to reasonable suspicion during my employment. If required, I agree to a drug testing prior and during employment or for post accident occurrences. 5) If I am employed, I agree to comply with and be bound by the safety and health rules and regulations, and rules of conduct of Comfort Keepers.

As a government contractor, Comfort Keepers is subject to governmental record keeping and reporting requirements to comply with federal and state laws and regulations. Required reporting includes statistical analysis of Comfort Keepers employment applicants with regard to gender, race, ethnicity, veteran and disability status. The information you provide will be used exclusively for purposes consistent with applicable laws and regulations. SUBMISSION OF THIS INFORMATION IS VOLUNTARY AND REFUSAL TO PROVIDE IT WILL NOT SUBJECT YOU TO ANY ADVERSE TREATMENT OR IMPACT ANY COMFORT KEEPERS EMPLOYMENT DECISION. If you would like to provide the information (it is voluntary), please use the box below to indicate: Gender(Male/Female), Race/Ethinic ID (Hispanic or Latino: A persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race/American Indian or Alaska Native (Not Hispanic or Latino)/Asian (Not Hispanic or Latino)/Black or African American (Not Hispanic or Latino)/Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)/White (Not Hispanic or Latino)/Two or More Races (Not Hispanic or Latino), Veteran Status (Non-Veteran,Disabled Veteran,Armed Forces Service Medal Veteran,Other Protected Veteran), Disability Status (Yes or No):

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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