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
	Car Insurance
	Chest X-Ray
	CNA License
	CPR Certification
	Driver's License
	First Aid Certification
	HCO#
	HHA Certification
	LVN/LPN Certification
	Passport
	Performance Evaluation
	Registered Nurse
	State ID Card
	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:

Position Applying for?

Why do you want this position? What makes you qualified for this role?

Are you currently registered as a Home Care Aide with the DSS? Effective January 1, 2016, Home Care Aides Must Be Registered with DSS Affiliated Home Care Aides will be required to provide their Home Care Organization with a criminal record statement (LIC 508). What is the Home Care Aide Registry? The Home Care Aide Registry is an Internet Web site of registered Home Care Aides and Home Care Aide applicants that is established and maintained by the California Department of Social Services. The Registry will include the following information: the individual’s name, registration number, registration status, registration expiration date, and, if applicable, the home care organization to which the affiliated home care aide or affiliated home care aide applicant is associated with.

Employees must at all times meet the following criteria: Drivers must have a current, valid driver's license for the state in which the employee performs his or her driving duties; and Drivers must maintain a clean driving record, i.e., must remain insurable under their insurance policy and maintain current automobile registration. Can you provide these requirements?

Do you have 3+ years professional experience in caregiving ? If so, what is your experience? (more details, the better):

What is your current availability, days and time of the week? Are you available on weekends? When are you available to start work?

Would you consider yourself a team player?

Why should I hire you over another person?

What are your strengths and weakness?

What would be your ideal working environment?

Can you tell me what you know about the company?

How do you deal with stressful situations?

Can you perform homemaking activities, which include (but are not limited to): Vacuuming, dusting, sweeping or mopping floors, Doing dishes, Changing bed linens, Doing laundry, Cleaning bathrooms, Prepares meals and snacks according to instructions:

Can you perform the essential functions of the job? Perform personal care activities that assist the client with activities of daily living which include (but are not limited to): Personal hygiene (assisting to bathroom or in using bedpan, bathing, care of mouth, skin and hair) Assisting with prescribed range of motion exercises , Ambulation, Eating, Dressing, Shaving, Measuring and preparing special diets :

Give me an example of how you dealt with a family member that was asking you to do things outside of your job description?

Would you ever accept money or gifts from a client?

How did you hear about us?

Disclaimer:

Caregivers of Land Park is an equal opportunity employer and will not discriminate in recruiting, hiring, training, promotion, transfer, discharge, compensation or any other term or condition of employment on the basis of race, religion, (including religious dress or grooming practices), color, age, sex, gender identity, gender expression, sexual orientation, genetic characteristic, national origin, marital status, medical condition (including pregnancy, breastfeeding, and related medical conditions), or on the basis of real or perceived mental or physical disability. Medi-Cal enrollment, military or veteran status, or any other protected characteristic according to federal and state law. Any employee who is aware of discriminatory or harassing conduct or who has any concern about a possible violation of this policy should immediately report the conduct or concern to his or her supervisor, designated human resource personnel or any corporate officer.

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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