Employment Opportunities

Name: *

First Last

Phone: *

Email: *

Are you at least 18 years old: *

Yes
No

Address *

Street Address Apt. No City State ZIP Code

Education: What is the highest grade you completed? *

Please list your occupation and/or volunteer experience *

What experience or training have you had in caring for the ill? *

Check all of the times you will be willing to work: *

morning
afternoon
evening

Is transportation a problem? *

Yes
No

Are there any physical problems which may limit the type of activities you would be able to perform (light lifting, bending or assisting patients with daily activities, such as bathing, dressing, grooming, meal assistance or walking) daily while working at the center? *

Yes
No

If yes, please explain: *

Please list 2 references (not your immediate family members) we may contact:

First Reference

First Reference Name:

First Reference Phone:

First Reference Address:

Second Reference

Second Reference Name:

Second Reference Phone:

Second Reference Address:

Please list two most recent previous employers:

First Employer

First Company Name:

First Company Phone:

First Company Date of Employment:

First Company Contact Person:

First Company Address:

Second Employer

Second Company Name:

Second Company Phone:

Second Company Date of Employment:

Second Company Contact Person:

Second Company Address:

How did you learn about the center?

PLEASE NOTE: All applicants must pass a physical examination before start of work. Please have your physician complete the center’s application.

Applicant Signature *

Date *

In order to deliver excellent medical and mental health care services, Today’s Care and Family requires that every employee submit to a drug test, and also a criminal background check. This profile will ensure the efficacy of all disciplines and the safety of all participants. Please answer the following questions:

Have you ever used illicit drugs within the last 5 years? *

Yes
No

If yes, please explain? *

Have you ever been treated inpatient or outpatient for substance abuse? *

Yes
No

If yes, please explain and include length of time and the number of treatments. *

Have you ever been convicted of a felony / crime? *

Yes
No

If yes, please explain. *

Have you ever been convicted of any child or adult abuse/neglect? *

Yes
No

If yes, please include when: *

DRIVER APPLICANTS ONLY:

Have you ever been convicted of any traffic violations on your driving record?

Yes
No

If yes, please explain:

Has your license ever been revoked/suspended?

Yes
No

If yes, please explain:

Do you object to providing a copy of your driving record?

Yes
No

If yes, please explain:

LICENSED PERSONNEL ONLY:

Has your license ever been revoked?

Yes
No

If yes, please explain:

DISCLAIMER: The results of testing and criminal background check will determine continued or future employment with Today’s Care and Family. I have answered the above questions truthfully, and to the best of my knowledge.

Signature *

Date *

Criminal Background and Random Drug Screening Consent Form

I fully understand failure to comply with criminal background investigations and random drug screening will result in denial or termination of employment.

I have been made aware of Today's Care and Family policy and procedure for Random Drug Screening and Criminal Background check. I have agreed to abide by all rules and regulations of Today's Care and Family. *

Yes
No

I will comply with random drug screening and a criminal background investigation. *

Yes
No

I fully understand failure to comply with criminal background investigations and random drug screening will result in denial or termination of employment. *

Name

This field is for validation purposes and should be left unchanged.

Criminal Background and Random Drug Screening Consent Form

Highlights

Dental Care for Seniors: "We need your help!"