Thrive Skilled Pediatric Care Application Form

Application Form

Trustient is an equal opportunity employer. We are dedicated to a policy of non-discrimination in employment based on race, age, sex, religion, disability, medical condition, national origin, or marital status.

Personal Information

First Name *

Last Name *

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Driver's License Number

Section 1 - Role and Availability

Social Security Number (required)

(Numeric Answer Only)

Date of Birth (required)

Position applying for? (REQUIRED)

Your Availability? (REQUIRED)

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Geographic preferences? (REQUIRED)

Willing to travel?

Yes No

Consent to drug screen? (REQUIRED)

Yes No

Do you have a reliable transportation? (REQUIRED)

Yes No

Preferred Method of Contact

How did you hear about us?

Section 2 - General Information

Have you had any moving violations in the last five years (ex: speeding tickets) (REQUIRED)

Yes No

Have you had residence outside the state of North Carolina in the last five years? (REQUIRED)

Yes No

Date Available? (REQUIRED)

Job Type?

Can you provide a driver's license and proof of auto insurance? (REQUIRED)

Yes No

Driver License Expiration Date:

Auto Insurance Expiration Date:

Have you ever been charged, convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other? (REQUIRED)

Yes No

If yes, please explain (REQUIRED)

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Are you certain of your answer to the above question as our background records research back to age 18?

Yes No

Did someone from Trustient refer you?

If yes, please list the name of the person.

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Do you have a smartphone (either Android or IOS-Iphone)?

Yes No

What is your cell phone number? (REQUIRED)

Do you have a current CPR certification? (REQUIRED)

Yes No

Who is your cellphone carrier? (REQUIRED)

Section 3 - Employment Verification

Are you a U.S. citizen? (REQUIRED)

Yes No

If you are not a U.S. citizen, please indicate VISA type and number.

Are you authorized to work in the U.S.? (REQUIRED)

Section 4 - Experience

Do you have home care experience? (REQUIRED)

Yes No

If yes to question 1 please describe your home care experience?

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Do you have pediatric experience? (REQUIRED)

Yes No

If yes to question 3 please describe your pediatric experience.

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Do you have in- home ventilator experience? (REQUIRED)

Yes No

If yes to question 5 please describe your ventilator experience?

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Do you have tracheostomy experience? (REQUIRED)

Yes No

If yes to 7 please describe your experience.

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Section 5 - Education

Highest Level of Education attained? (REQUIRED)

Did you graduate? (REQUIRED)

Yes No

Years Attended (From/To): (REQUIRED)

Additional Education (vocational, undergraduate, etc.)

Yes No

Section 6 - Other Certifications and Licenses

Other Licenses

Other Certifications:

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Section 7 - Current Employment

Current Employer: (REQUIRED)

Address:

City: (REQUIRED)

State: (REQUIRED)

Zip Code:

Start Date: (REQUIRED)

End Date:

Hours Worked:

Position/Title: (REQUIRED)

Describe Your Responsibilities: (REQUIRED)

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Supervisor's Name/Title: (REQUIRED)

Supervisor's Phone:

Reason for Leaving: (REQUIRED)

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May we contact?

Yes No

Section 8 - Employment History

Previous Employer Name:

Address:

Phone Number:

(Numeric Answer Only)

Start Date:

End Date:

Hours Worked:

Position Title:

Describe your responsibilities:

Supervisors Name/Title:

Supervisors Phone:

(Numeric Answer Only)

Reason for Leaving?

May we Contact?

Yes No

Section 9 - Employment History

Last Employer:

Address:

City:

State:

Zip Code:

Start Date:

End Date:

Hours Worked:

Position/Title:

Describe Your Responsibilities:

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Supervisor's Name/Title:

Supervisor's Phone:

Reason for Leaving:

Show Plain Text

May we contact?

Yes No

Section 10 - Reference 1 (List professional or business only)

Name: (REQUIRED)

Company or Relationship: (REQUIRED)

Phone: (REQUIRED)

Section 11 - Reference 2 (List professional or business only)

Name: (REQUIRED)

Company or Relationship: (REQUIRED)

Phone: (REQUIRED)

Section 12 - Reference 3 (List professional or business only)

Name

Company or Relationship:

Phone

Section 13 - Emergency Contact Information

First Name: (REQUIRED)

Last Name: (REQUIRED)

Address:

City:

State:

Zip Code:

Phone 1: (REQUIRED)

Phone 2:

Relationship: (REQUIRED)

I certify that information contained in this application is true and complete. I understand that false information may prevent me from moving forward in the hiring process and for my immediate termination if discovered post hire. I authorize the verification of all information listed above.

Signature