Employment Opportunities Download Application Name: * Required First Last Phone: * RequiredEmail: * Required Are you at least 18 years old: * RequiredYesNoAddress * Required Street Address Apt. No City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Education: What is the highest grade you completed? * RequiredPlease list your occupation and/or volunteer experience * RequiredWhat experience or training have you had in caring for the ill? * RequiredCheck all of the times you will be willing to work: * Required morning afternoon evening Is transportation a problem? * RequiredYesNoAre 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? * RequiredYesNoIf yes, please explain: * RequiredPlease list 2 references (not your immediate family members) we may contact:First ReferenceFirst Reference Name:First Reference Phone:First Reference Address:Second ReferenceSecond Reference Name:Second Reference Phone:Second Reference Address:Please list two most recent previous employers:First EmployerFirst Company Name:First Company Phone:First Company Date of Employment:First Company Contact Person:First Company Address:Second EmployerSecond 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 * RequiredDate - must be mm/dd/yyyy format * Required Date Format: MM slash DD slash YYYY 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? * RequiredYesNoIf yes, please explain? * RequiredHave you ever been treated inpatient or outpatient for substance abuse? * RequiredYesNoIf yes, please explain and include length of time and the number of treatments. * RequiredHave you ever been convicted of a felony / crime? * RequiredYesNoIf yes, please explain. * RequiredHave you ever been convicted of any child or adult abuse/neglect? * RequiredYesNoIf yes, please include when: * RequiredDRIVER APPLICANTS ONLY:Have you ever been convicted of any traffic violations on your driving record?YesNoIf yes, please explain:Has your license ever been revoked/suspended?YesNoIf yes, please explain:Do you object to providing a copy of your driving record?YesNoIf yes, please explain:LICENSED PERSONNEL ONLY:Has your license ever been revoked?YesNoIf 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 * RequiredDate - must be mm/dd/yyyy format * Required Date Format: MM slash DD slash YYYY 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. * RequiredYesNoI will comply with random drug screening and a criminal background investigation. * RequiredYesNoI fully understand failure to comply with criminal background investigations and random drug screening will result in denial or termination of employment. * RequiredNameThis field is for validation purposes and should be left unchanged.