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:

Certifications and Credentials:

Please check all that apply, and enter the expiration date and any notes as applicable.

Active	Type	Expiration Date	Notes
	1st Annual Sup Visit
	1st Bloodborne Pathogens Cert
	1st Perform Review
	2nd Annual Sup Visit
	2nd Bloodborne Pathogens Cert
	2nd Perform Review
	3rd Annual Sup Visit
	3rd Bloodborne Pathogens Cert
	3rd Perform Review
	4th Annual Sup Visit
	4th Bloodborne Pathogens Cert
	4th Perform Review
	90 day supervisory visit
	Background Check
	Car Insurance
	Chest X-Ray
	CNA License
	Covid19-vaccine
	Driver's License
	MVR Report
	TB Screen
	Tuberculosis Test
	Vehicle Registration

+ 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:

Tell me about your most recent work experience and why you left:

How did you hear about New Estuary Home Care?

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

Are you at least 18 years old?

If hired, when are you available to begin?

Will providing transportation for our clients be a problem?

Do you have a valid driver's license, a clean driving record, and your own reliable vehicle?

Please specify the number of years experience that you have that are relatable to the position.

Have you been fully vaccinated for COVID-19? Are you willing to get the Covid-19 Boosters as the need arises? This is a condition of employment. :

Do you consent to a criminal background check and a Healthcare Personnel Registry Check as part of the hiring process? :

Disclaimer:

New Estuary Home Care retains the right to verify all information provided by me. I authorize New Estuary Home Care to contact any person, school, organization, or employer listed to obtain all necessary information for verification. I release all individuals who provide such information from any liability or damages to me or anyone acting on my behalf. I also waive any written notice of the release of such information that may be required by state or federal law. Any falsification, misrepresentation, or omission—whenever discovered—may result in immediate dismissal. If hired, I understand that my employment with New Estuary Home Care is at-will. This means that I may terminate my employment at any time, and the company may also terminate my employment at any time, with or without cause. New Estuary Home Care is committed to providing equal employment opportunities to all employees and applicants. We prohibit discrimination and harassment of any kind based on race, color, religion, age, sex, national origin, disability, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local law. This policy applies to all aspects of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

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