Volunteer Application

Name*

Email*

example@example.com

Phone Number*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you speak a language in addition to English?*

YesNo

Are you a licensed medical professional?*

YesNo

Emergency contact person*

First NameLast Name

Emergency contact phone number*

Resume Upload*

Cover Letter Upload

Certifications/License*

Position Applying For*

Compensation Expectation?*

Compensation Type?*

HourlySalary

Specialty or Care Area*

Is there a shift that you prefer to work?*

Please indicate highest number of hours you are able to work in a day?*

What type of care experience do you have?*

Please indicate highest level of patient care

Please indicate if you have any pre-existing conditions, especially any with COVID-19 increased risk*

YesNoOther

Agreement and Signature

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a employee, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate termination and I may not be eligible to be employed again at the Heights Corporation and/or Silver Square Heights Home Care.

Our Policy

It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age or disability. In efforts to protect our residents from communicable disease, the Heights Corporation and/or Silver Square Heights Home Care requires you to provide proof of a negative TB test that is no older than one year to be provided prior to any volunteer work. I authorize the Heights Corporation and its affiliates to investigate all statements contained in this application including records of any former employers, police departments, care giver background checks, drug testing, and other references or sources concerning me. I authorize all such reference and sources (and the company) to release this information without liability for damage resulting from such release. I waive any written notice of the release of such records that may be required by state of federal law.

Signature

Employee Application