Thank you for your interest in working for our agency.

Please submit the application below to be considered for a position as a caregiver.

Applicant Information:
*:
*:
:
:
*:
*:
:
*:
*:
*:
:
*:
*:
:
:
:
Match Criteria:
Indicate caregiver's skills and limitations. These will be used for matching the caregiver with clients.

General

Transfers

Pets

Education & Training:
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
CPR Certification
Driver's License
HCA Certification
HHA Certification
LiveScan/Fingerprinting
LVN/LPN Certification
Performance Evaluation
Registered Nurse
State ID Card
Tuberculosis Test

+ Add Additional Certification or Credential

Employment History:
Please provide your most recent positions of employment.

+ Add Additional Employer

Professional References:
Please provide professional references.

+ Add Additional Reference

Additional Information:
Disclaimer:
Seniors Helping Seniors® is an equal opportunity employer and complies with all applicable laws enforced by the California Civil Rights Department. We do not discriminate based on protected characteristics under state or federal law. I certify that the information provided on the online Wellsky application is true, accurate, and complete to the best of my knowledge. I understand that any false statements or omissions may result in disqualification from employment or termination if hired. Seniors Helping Seniors® will provide a separate disclosure and authorization form for a required background check, including a criminal history check. I will release information about my background to all parties of liability for any damage whatsoever that may result from furnishing this information. I also release SHS from any and all damages for doing such an investigation. I permit Seniors Helping Seniors® to contact any of my personal references for the purpose of processing my application. I understand that any offer of employment may be contingent upon the successful completion of a background check conducted only after a conditional offer of employment and in accordance with applicable laws. I may not provide services through Seniors Helping Seniors® in-home services until the background check has been completed and I am cleared to begin work. If hired, employment with the Company will be at-will. This means that either the employee or the Company may terminate the employment relationship at any time, with or without cause or notice, in accordance with applicable law.
Signature:

To what day do you want to copy this shift?

Date:

Please choose an ID, date range and payer for the new authorization.

New ID:

From*:

To*:

Paid By*:

at

Right Now Scheduled Time

Reason Code Message

Reason Code :

Reason Code :

Action Taken :

Action Taken :