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:

Hours wanted weekly:

Date Of Birth:

Certifications and Credentials:

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

Active	Type	Expiration Date	Notes
	3 Hr Extra Dementia
	Car Insurance
	CNA License
	Driver's License
	Driving Record
	Food Safety Orientation
	HCA Certification
	HHA Certification
	In the Know- Food Safety
	Introduction to Gems
	Performance Evaluation
	Sapphire Training
	State ID Card
	Understanding Alzheimer's & Dementia
	Universal Precautions and Bloodborne Pathogens
	WSP

+ Add Additional Certification or Credential

Additional Information:

Have you worked for Senior Helpers before, under any name? If yes, please provide name worked under. :

How do you plan to get to work?

What type of health care certifications do you have? This is not required. We provide free Washington HCA training for candidates. :

To what day do you want to copy this shift?

Date:

Please choose an ID, date range and payer for the new authorization.

New ID:

From*:

To*:

Paid By*:

at

Right Now Scheduled Time

Reason Code Message

Reason Code :

Reason Code :

Action Taken :

Action Taken :

I attest I have proper documentation to support this visit.