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
	a. Complete Docusign Registration Pack
	b. Driver's License
	c. Drivers License Verification
	d. Social Security Card
	e. CPR
	f. Car Insurance
	g. Health Statement
	h. Background Results (Eligible)
	i. HHA Training Certificate
	j. HHA School Verification
	k. Professional License (CNA,RN,LPN)
	l. Professional License Verification ANNUAL
	m. Reference Check and/or Employment History Verification
	n. Professional Liability Insurance
	o.1 Alzheimers Initial 1 Hour Cert. Elderly Affairs
	o.2 Alzheimer's Training Additional 2-4 Hours
	p. Assistance w/Meds Training
	q. HIPAA certification
	r. HIV 4 Hour Training
	s. Add Caregiver to HeyMarket with Male/Female Tag
	t. Add Tags to Caregiver in ClearCare
	u. Photo in ClearCare and Heymarket
	v. AHCA Background Portal Added
	w. Additional Documentation
	x. Introductory Email Sent
	y. Completed File Uploaded to DropBox

+ 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 are your long-term dreams and aspirations? Please include both personal and professional goals.

Please type in your state license number and the date license was obtained, as well as any additional information regarding renewal of your licenses, registrations, or certificates:

Please type in your Social Security number. We must have this in order to complete a background screening on you as required by the state. This information remains completely confidential.

What is your current availability?

Are you willing to work nights? Are you willing to work weekends?

Are you willing to travel to travel within our service range? (Lee and Collier County):

Signature:

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.

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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