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:

Certifications and Credentials:

Please check all that apply, and enter the expiration date and any notes as applicable.

Active	Type	Expiration Date	Notes
	90 Day Evaluation
	Car Insurance
	CPR & First Aid
	Driver's License
	PCA or CNA (if PCA put expiration as 01/01/2075)
	Skills Exam
	Tuberculosis Test
	Yearly Eval

+ 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:

Do you have a high school diploma or GED?

Are you an active CNA in GA? (A CNA is not required):

Do you have a valid driver's license?

Do you have reliable transportation?

Are you willing to travel to clients' homes?

What counties are you willing to work in? White Lumpkin Habersham Hall Dawson Stephens:

Have you worked as a caregiver before?

How many years of caregiving experience do you have?

Do you any scheduling restrictions?

How would a previous client or supervisor describe you?

If a client falls, what would you do?

How did you hear about Integrity Home Care?

Disclaimer:

Integrity Home Care of North Georgia is an equal opportunity employer and is committed to providing equal employment opportunities to allemployees and applicants without regard to race, color, religion, sex, sexual orientation, gender identity or expression, national origin, age,genetic information, disability, or veteran status. We do not discriminate on the basis of any protected characteristic. As part of our hiring process, all applicants will be subject to a drug screening and background check. This process may include, but is notlimited to, checking references, verifying educational and employment history, conducting criminal background checks, and screening for illegaldrug use.By submitting your application, you acknowledge and agree to consent to these pre-employment screenings as part of our hiring process.Please note that the results of these screenings will be used as a factor in determining your eligibility for employment with Integrity Home Care. If you require any accommodations during the application or hiring process, please inform our Human Resources department, and we will makereasonable efforts to accommodate your needs in accordance with applicable 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.

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