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:

Match Criteria:

Indicate caregiver's skills and limitations. These will be used for matching the caregiver with clients.

Max client weight for transfers:

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
	Car Insurance
	Chest X-Ray
	CNA License
	COVID 19 Vaccine
	CPR Certification
	Driver's License
	First Aid Certification
	HHA Certification
	State ID Card
	Tuberculosis Test

+ 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 list your experience care-giving, either personally or professionally.

Do you approve Assisting Hands West Austin to contact 2 of your listed professional references?

What is your availability? Are you able to work days vs nights, weekdays vs weekends? :

Please list any languages you speak fluently:

Disclaimer:

I give authorization for Assisting Hands West Austin to contact my references listed and for the references to release to Assisting Hands Home Care all information regarding my service (including dates of employment), character, and conduct. It is the policy of Assisting Hands Home Care to run a pre-employment background check on each prospective employee in accordance with the Texas Administrative Code Rule 97.247 and Health and Safety Code 253.008. Items included in the screen will be: A full criminal history check, Social Security Verification, MVD record, Employee Misconduct Registry, and Nurse Aide Registry Check. The results of your background check will not be release to anyone but the Assisting Hands staff and will remain confidential. By signing below you authorize Assisting Hands West Austin to perform this check in accordance with State Law.

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.