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 Performance Evaluation
	Car Insurance
	CPR Certification
	DCW Certification
	Driver's License
	Fingerprint Clearance Card
	First Aid Certification
	Passport
	Performance Evaluation

+ 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 consent to receiving text communications related to your job application via SMS from Desert Hearts Nursing and Home Care, which may include autodialed and automated messages, at the mobile number provided? Message frequency may vary and applicable data rates may apply.*:

Do you have reliable transportation?

Are you 18 years of age or older? :

What days/hours are you available to work?

Do you have any physical limitations that would prevent you from lifting or assisting clients?

Have you ever been convicted of a felony or misdemeanor? (Yes/No) If yes, please explain:

Do you acknowledge that caregiving requires patience, flexibility, and commitment? (Caregiver Question only):

If offered a position, are you willing to undergo a comprehensive background check and drug screening as part of the hiring process?

Were you referred by a current Desert Hearts Home Care employee? If yes, please provide the employee's name. :

Disclaimer:

By submitting this application for employment with Desert Hearts Nursing and Home Care, I understand and agree that my employment, if offered, will be at-will, meaning that either I or Desert Hearts Nursing and Home Care may terminate the employment relationship at any time, with or without cause or notice, in accordance with Arizona law. I certify that the information provided on this application, my resume, and any accompanying documents is true, complete, and accurate to the best of my knowledge. I understand that any false statements, omissions, or misrepresentations made during the hiring process may result in disqualification from consideration for employment or, if discovered after employment begins, could lead to termination. I authorize Desert Hearts Nursing and Home Care and its agents to contact my former employers, educational institutions, references, or other relevant individuals or entities to verify the accuracy of the information provided, and I release all parties from any liability that may arise from such verification. I further understand that Desert Hearts Nursing and Home Care may conduct a background investigation, including criminal history, credit checks, driving records, and other relevant inquiries, as allowed by Arizona law, and that I will be informed of such checks and my consent obtained if required. I acknowledge that Desert Hearts Nursing and Home Care is an equal opportunity employer and that all employment decisions will be made without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other protected status as required by law. Additionally, I understand that Desert Hearts Nursing and Home Care maintains a drug-free workplace and that any offer of employment may be contingent upon successfully passing a pre-employment drug screening, in accordance with Arizona law. By signing below, I acknowledge that I have read, understand, and agree to the terms of this application, and I understand that this document does not constitute a contract of employment.

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.

General

Transfers

Pets