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
	ADDITIONAL TRAINING
	Car Insurance
	Chest X-Ray
	CNA License
	COVID-19 Vaccine
	CPR Certification
	Driver's License
	First Aid Certification
	HCA Registry Number
	HCA TRAINING
	HHA Certification
	LVN/LPN Certification
	MVR (If Driving for PCH)
	Passport
	Performance Evaluation
	Registered Nurse
	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:

EMERGENCY CONTACTS: (Please include the relationship to you and phone numbers):

HAVE YOU EVER SUBMITTED AN APPLICATION HERE BEFORE? YES / NO (If yes when?):

LIST 3 PERSONAL REFERENCES: (Please include thier relationship to you, how long you have known them and phone numbers):

ADDITIONAL COMMENTS ABOUT YOUR AVAILABILITY:

WHAT DATE ARE YOU AVAILABLE TO BEGIN WORK?

TODAY'S DATE:

HOW MANY YEARS EXPERIENCE DO YOU HAVE AS A CAREGIVER?

ARE YOU ABLE TO PERFORM ALL THE ESSENTIAL FUNCTIONS OF THE JOB FOR WHICH YOU ARE APPLYING? YES / NO (If no please explain):

HOW DID YOU HEAR ABOUT PACIFIC COAST HOME CARE?

DUE TO THE NATURE OF THE BUSINESS, NO GUARANTEE CAN BE MADE THE THE SCHEDULE OR THE AMOUNT OF HOURS WORKED. PLEASE LIST DAYS AND TIMES YOU ARE CURRENTLY AVAILABLE TO WORK: (Ex. Tuesday through Friday nights) :

DESCRIBE WHY YOU ARE PURSUING A POSITION AS A CAREGIVER:

Disclaimer:

IMPORTANT: IT IS RECOMMENDED THAT YOU BRING DOCUMENTS ESTABLISHING YOUR LEGAL RIGHT TO WORK IN THE UNITED STATES WITH YOU TO YOUR INTERVIEW. EXAMPLES OF ACCEPTABLE I.D.’S INCLUDE A SOCIAL SECURITY CARD, RESIDENT ALIEN CARD, AND/OR A VALID STATE DRIVER’S LICENSE / I.D. CARD. By signing this application, I acknowledge that my employment is at-will, meaning that the terms of employment may be changed with or without notice, with or without cause, including but not limited to termination, demotion, promotion, transfer, compensation, benefits, duties, and location of work. I have entered into my employment with PACIFIC COAST HOMECARE voluntarily, and acknowledge that there is no agreement or contract express or implied between PACIFIC COAST HOMECARE and me for continuing employment or long-term employment. While supervisors and managers have certain hiring authority, no supervisor or manager or representative of the Company has any authority to alter this at-will relationship. I certify that all statements made in this application are true and complete, and that any misstatement of material fact will subject me to disqualification or future dismissal if hired.

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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