Caregiver Application | WellSky Personal Care

Thank you for your interest in working for our agency.

Please submit the application below to be considered for a position as a caregiver.

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:

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
	01 - Personnel Record HCS 501
	02 - Criminal Record Statement LIC 508
	03 - Live Scan Fingerprinting
	04 - Abuse Statement SOC 341A
	05 - 2 Hour Orientation Training
	06 - 3 Hour Safety Training
	07 - 5 Hour Annual Training w/SexHarTrain
	08 - HCA License
	09 - Annual MVR
	10 - COVID Vaccine
	Car Insurance
	Chest X-Ray
	CNA License
	CPR Certification
	Driver's License
	First Aid Certification
	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:

What is your work availability?

What areas in Alameda and Contra Costa Counties are you available to work in?

Are you willing to provide transportation in your personal vehicle?

Do you have any work restrictions? e.g. Pets, smoke.

May we have permission to contact your past and current employers in regards to your work history?

Disclaimer:

All applicants are considered for all positions without regard to race, religion, color, sex, gender, sexual orientation, pregnancy, age, national origin, ancestry, physical/mental disability, medical condition, military/veteran status, genetic information, marital status, ethnicity, citizenship or immigration status or any other protected classification, in accordance with applicable federal, state, and local laws.

Signature: