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:

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
	1 Companion Only
	2 RN Cert
	3 RN Cert
	Car Insurance
	CERT - CNA Training
	CERT - PCA TRAINING
	CNA License
	DMV RECORD
	Driver's License

+ 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:

Please tell us how you heard about caregiver jobs at Home Care Assistance. (Examples: Craig's List, Web Search, Employee Referral, Indeed, etc.):

Do you have a valid Virginia driver's license?

How many traffic/driving offenses have you had in the last three years?

Are you legally authorized to work in the United States?

This job may require you to transfer 75 pounds of dead weight to/from bed, commode, couch, wheelchair, etc. Are you able to perform this task?

Are you currently working anywhere else?

Are you able to work 12 hour day or night shifts on a 7 day on 7 day off rotation? :

Are you available to work 24 hour live-in shifts? You stay at the client's home for 7 days on and then are off for 7 solid days. You have your own bedroom/bathroom and an opportunity to earn over $1,400 for that 7 day period. :

Are you able to work in homes that have pets?

Do you smoke cigarettes? Can you work in a home where the client smokes cigarettes? :

Are you available to work jobs within 30 miles of your home?

Do you own your own reliable transportation that you can use on a regular basis for transportation to a job? If so, please list make and model. :

How many years of professional caregiving experience would you say that you have (including experience working directly for clients or family)?

Are you willing to undergo a background check, in accordance with local law and regulations?

Disclaimer:

IMPORTANT: All caregiver positions at Home Care Assistance (HCA of Virginia, Inc.) are considered TEMPORARY (seasonal) due to the frail condition of our elderly clients. Continued employment is not guaranteed for any caregiver as all employment is at-will, indefinite, and not for any specific period of time.

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*:

Right Now Scheduled Time

Reason Code Message

Reason Code :

Action Taken :

I attest I have proper documentation to support this visit.