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:

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:

Do you have a high school diploma or GED? Please specify which, high school and graduation year. :

How did you hear about us? If someone referred you, please list their name.

Birth Date:

Email:

Are you seeking full or part time work and what is your availability? Do you have any scheduling restrictions?

Do you drive or take the bus?

Have you lived in Pennsylvania for the past 2 years?

Have you worked for a Home Care Agency, Hospital,Nursing Home or as a caregiver in a private home? Please explain your experience. :

Have you bathed, changed, transferred a client from a wheelchair, used a bed pan, assisted with depends, used a hoyer lift and/or provided additional personal care to a client or patient? Please describe your experience. :

Do you have any certifications? Such as CNA, Nurses Aide, Medical Assistant, Certified Home Health Aide, Patient Care Tech?

Is it legal for you to work in this country?

Are you named in the Statewide Central Registrar as a perpetrator of a founded or indicated report of child abuse?

Have you been convicted of a crime? If yes, explain. :

Have you completed the entire application? If you have not filled out your professional references and employment history completely,please go back and do so as this information is required to process the application. :

Disclaimer:

I swear that I have answered truthfully regarding any criminal history I may have. I understand that if the certification is contradicted by the criminal clearance results, employee may face immediate dismissal from employment in the waiver program. I swear/affirm that I am not disqualified from employment under 18 Pa.C.S. § 4911 (relating to tampering with public records or information No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position applied for may, however, be considered. 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 Golden Rule Home Care to verify their accuracy and to obtain reference information on my work performance. 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.

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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