Caregiver Application | WellSky Personal Care

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:

What time of day are your desired shifts? (for example, AM, PM or NOC) Are you open to working short shifts? Long shifts?

What is your current weekly availability? Sunday: Monday: Tuesday: Wednesday: Thursday: Friday: Saturday:

Please list the illnesses and medical conditions of past clients you have worked with (For example: Alzheimer’s, Dementia, Hospice, Incontinence, ALS, etc.):

Are you willing to do household chores, such as light housekeeping and laundry?

Please indicate in the box below one of the following: Hispanic/Latino, White, Black or African American, Native Hawaiian or Other Pacific Islander, Asian Indian or Alaskan Native Two or more races Prefer not to answer:

Sex: Female, Male, or Prefer not to answer:

Are you comfortable working with both male and female clients? If no, please explain.

If hired, can you provide verification of your legal right to work in the United States?

Max client weight:

Are you a registered Home Care Aide with the Department of Social Services?

Please provide your HCA (Home Care Aide) Registration number, if applicable:

Why do you want to work at Chamberlin Care?

We strive to serve our clients with service, excellence, and love. How do you embody these attributes in your personal and professional life?

How did you hear about Chamberlin Care?

Disclaimer:

AT-WILL EMPLOYMENT It is my understanding that this employment application, or the granting of an oral interview, does not represent a contract of employment or a promise of future benefits by this organization. I understand and agree that, if hired, my employment will be at-will in nature and may be terminated, with or without cause, at any time, by either myself or my employer. I also understand that this written statement supersedes any and all oral representations made by agents or representatives of this organization. CERTIFICATION OF TRUTH AND ACCURACY I certify that the information in this application is true, complete and correct. I understand that false answers, statements, or significant omissions made by me on this form shall be sufficient cause for denial of employment or discharge. NOTIFICATION AND AUTHORIZATION TO REQUIRE A TUBERCULOSIS SCREENING I hereby certify that, if hired, I will disclose any limitations I have that may impact my ability to do the essential functions of the job. I further understand as a Health care employee I will be required to undergo a two-step Tuberculin skin testing by a PPD test or chest x-ray. NOTIFICATION AND AUTHORIZATION TO CONDUCT BACKGROUND INVESTIGATION I understand that I may be subject to a background check, and hereby authorize the California Department of Social Services (CDSS), to investigate my background to determine any and all information of concern as to my record, whether same is of record or not, and I release employers and persons named in my application from all liability for any damages on account of his/her furnishing said information. Additionally, you are hereby authorized to make any investigation of my personal history, educational background, military record, motor vehicle records and criminal records through an investigative or credit agency or bureau of your choice. I authorize the release of this information by the appropriate agencies to the investigating service. This authorization, in original or copy form, shall be valid for this and for any future reports and updates that may be required. I understand that passing the background check is a condition of employment. A negative background check can be grounds for dismissal, even if an offer has been made to me and I have been hired. Non-Discrimination Policy: Chamberlin Care is committed to the principle of equal opportunity in education and employment. The company does not discriminate on the basis of sex, race, color, creed, national origin, age, religion, sexual orientation, gender identity, gender expression, veteran status, or disability in admission to, access to, treatment in, or employment in its programs and activities. The following person has been designated to handle inquiries regarding Chamberlin Care nondiscrimination policies: Chief Executive Officer Ben@ChamberlinCare.com

Signature:

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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