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:

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:

At Seniors Helping Seniors, we employ mature adults. Are you at least 40 years of age?

Do you have a valid driver's license and a reliable vehicle available for transportation?

Are you a citizen of, or legally authorized to work in, the United States?

Have you ever been convicted of a felony or misdemeanor for which your record has not been sealed or expunged? If yes, please describe.

Please provide information on any additional education or training beyond what is already included in the application.

How did you hear about Seniors Helping Seniors?

Why would you like to work for Seniors Helping Seniors?

Do you have prior caregiving experience? If yes, please describe, including if you have any Alzheimer's/Dementia experience.

How far are you willing to drive to a client's home (e.g., 5-10 minutes, 15-20 minutes, 25-30 minutes, 35-40 minutes, 45-50 minutes, 55-60+ minutes)?

Do you have any physical restrictions or limitations? If yes, please describe.

What is your desired hourly rate of pay and desired number of weekly hours?

Disclaimer:

I certify that the facts contained in this application are true, accurate and complete to the best of my knowledge and belief; and I understand that, if hired by Seniors Helping Seniors of Southwestern PA, falsified statements on this application or omissions shall be grounds for immediate dismissal/termination. I hereby authorize all persons, companies, schools, law enforcement and departments of transportation/motor vehicles to release any and all information about my background, and release all parties from liability for any damage whatsoever that may result from furnishing this information. I also release Seniors Helping Seniors of Southwestern PA from any and all damages for performing my background investigation.

Signature: