* = Required Information
Personal Data

Emergency Contact information

Job Information


RN PT LP/VN CNA
OT PTA Clerical Other

Work Experience/Skills

Please list the number of years you have experience in each area (min 1 year exp.) and are clinically competent to work:
Burn
L & D
MICU
NICU
PACU
SICU
CCU
Other 		ENT
Rehab
Nursery
Dialysis
Geriatic
PEDI ICU
Med/Surg
Other 		Pediatrics
Telemetry
Psychiatry
Stepdown
Oncology
Neurology
Open Heart
Other 		Detox/Drug Rehab
Post Partum
Orthopedics
Mother/Baby
Recovery Room
Operating Room
Emergency Room
Other

Previous Facility Types Worked: Check All That Apply --

Hospital Hospice Nursing Home Rehab Private Duty Assited Living/Residential Treatment

Spanish French German Other

Fill-Time Part-Time Contract Travel

Check the days of the week you are available to work:

Monday Tuesday Wednesday Thursday Friday Saturday Sunday Holidays available to work

Yes No

Certifications: Check all applicable certifications and enter expiration date:

ACLS
BCLS
CPR
PALS
Other
IV
NALS

Work Experience: List all of your work experience beginning with your most recent job. You will be asked to explain all gaps in employment. Attach additional sheet(s) if necessary.


Yes No

Yes No

Yes No


Yes No

Yes No

Yes No


Yes No

Yes No

Yes No

Additional Information:


Yes No

Yes No

Yes No

Newspaper Trade Publication Job Fair/Open House Internet Site
Company Employee — Name:

I understand that I must report all accidents to my immediate supervisor and to LovingTouch Home Health Care - - No MATTER HOW SLIGHT. Yes

I also understand that I must wear all required personal protection equipment (PPE). Yes
The penalty for not wearing PPE is disciplinary action, up to and including termination.

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ACKNOWLEDGMENT (Please read carefully and sign)

In signing this application, I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview for employment may jeopardize my chances for employment and be cause for my immediate dismissal from employment.

I give LovingTouch Home Health Care permission to use any information in this application to enable it and its agents to verify the information contained in this application I also authorize present and former employers, educational institutions I have attended, credit agencies, all references, and any other persons to answer all questions asked by LovingTouch Home Health Care with regard to any of the subjects covered by this application. I also understand that in connection with my application for employment or my employment, LovingTouch Home Health Care may conduct a criminal background investigation and that my employment may be contingent on the results of such investigation. I release LovingTouch Home Health Care, its agents, and all affiliated entities, as well as any person or situation that provides any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure of such information.

In consideration of my employment and of my being considered for employment by LovingTouch Home Health Care, I agree to abide by all rules and regulations, which I understand are subject to change at any time for any reason without prior notice. I also understand that if employed, I will be an employee at will and employed for no definite period of time. I understand that either LovingTouch Home Health Care or I can terminate my employment at any time, with or without cause and with or without advance notice. I further understand that no communication, whether oral or written, by any representative of LovingTouch Home Health Care, at any time, can constitute a contract of employment. No representative or agent of LovingTouch Home Health Care, has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing.

I am willing to submit to a physical examination, including the analysis for the detection of the use of unlawful drugs or substances in accordance with the applicable laws. If I receive an offer of employment I agree that my continued employment may be contingent on the results.

I understand that all professional staff fully indemnifies LovingTouch Home Health Care against any and all liability and responsibility associated with his or her professional duties. The Professional maintains his or her license as required by law, professional liability coverage and adheres to other responsibilities as agreed to under Kansas State Laws.

I HAVE READ THE ABOVE AND FULLY UNDERSTAND IT.


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