Employee Application Form

I hereby agree with and will uphold the Core Values of You Medical*

Yes, I agree.

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you have any physical disabilities or other health concerns that would prevent you from certain tasks? Please explain.*

The following policy will be reviewed with you at the Orientation.

POLICY

All reasonable effort will be made to assure clients and co-workers are protected from occupational exposure to bloodborne pathogens.

PROCEDURES

All procedures involving blood or other potential infectious materials (OPIM) will be performed in such a manner as to minimize splashing, spraying, or the generation of droplets.

Food and drink may not be kept in refrigerators, freezers, shelves, cabinets, or on countertops where blood or OPIM could be present.

Eating, drinking, applying cosmetics, or handling contact lenses are prohibited in work areas where there is a reasonable likelihood for occupational exposure to bloodborne pathogens.

Staff and volunteers who have a common communicable disease (cold, rhinitis, etc.) will take the following precautions:

Avoid client contact, if possible.
Use good hand washing techniques.
Avoid excess talking, coughing or sneezing while near clients.
Staff with active respiratory infection will wear a mask during client contact.
Cover mouth with tissue or crook of elbow when coughing or sneezing.
Dispose of used tissues promptly in a waste receptacle.

Staff and volunteers with dermatitis and/or skin lesions will be discouraged from handling equipment. They must wear gloves and cover area with long sleeves if indicated or take precautions to decrease the likelihood of contamination.

Clinic staff who have bloodborne infection (such as HIV, Hepatitis B or C) will take the following precautions:
Refrain from performing invasive procedures.
Utilize good hand washing techniques.
Avoid contact with clients with communicable diseases.
Use plastic bags to dispose of soiled tissues, band-aids, tampons, sanitary napkins, and soiled gloves. Close and secure the bag tightly and dispose.
Staff and volunteers with a fever or tuberculosis, which may pose a risk to a pregnant client, will not have direct contact with a client. If a worker has tuberculosis (or thinks they might have tuberculosis), they cannot come to You Medical or volunteer in any capacity until that person is totally cleared by the Health Department as fully treated and non-contagious.
Staff and volunteers who may have a contagious condition may contact the healthcare professional in charge. If it is determined that the condition may pose a risk to a client, she/he will be asked to go home for the day or to not report to You Medical that day.

Do you agree to comply with You Medical's policy above in regards to bloodborne infections, other communicable diseases and contagious conditions (i.e HIV, Hepatitis B or C, tuberculosis)?*

Yes, I agree.No, I do not agree.

What does your availability look like?*

	Mornings	Afternoons	Evenings	Nights
Monday
Tuesday
Wednesday
Thursday
Friday

What job are you applying for? *

What job are you applying for?*

Please list any skills, hobbies or interests that you would have to offer in the position.*

Do you speak any other languages fluently; if so, what language(s)?*

How many hours a week can you dedicate to working/volunteering?*

Are you at least 18 years of age?*

YesNo

Upload Resume*

Upload Cover Letter

What is the highest level of education you have attained?*

Please describe any relevant training and work you have had.*

Where did you graduate High School?*

Where did you graduate college and what was your degree?

If you are employed, how many hours do you work in a week?*

Employer's Name*

First NameLast Name

Work Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employer's Phone Number*

Please enter a valid phone number.

Can we contact your current/most recent employer?*

YesNo

Past Employer's Name

First NameLast Name

Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Past Employer's Number

Please enter a valid phone number.

Can we contact your past employer?

YesNo

I understand that I will be required to undergo a background check before being accepted as a filly trained volunteer.*

Yes, I understand

What Church do you attend?*

Pastor or Church Leader's Name*

Pastor or Church Leader's email or phone number*

Describe your involvement with any other non-profit organization, ministries or volunteer positions*

What religion or spiritual belief do you identify with?*

Do you attend church or another type of worship service? If so, please describe where and how often.*

Please describe your religious belief. (ie. What do you believe about the world, God, salvation, sin etc.?)*

I understand that You Medical in a Christian pro-life ministry and that this guides and directs the way they operate as a non-profit organization and ministry*

Yes, I acknowledge and understand this statement

Please describe in one sentence when you believe life begins.*

Under what circumstances would you consider abortion a viable option?*

Has your life been affected by an unplanned pregnancy or abortion? Please explain.*

Important: How to Save Your Application Progress

Mission Statement:

Vision Statement:

Statement of Faith

Employee Application Form

Contact Information

Emergency Contact and Health Considerations

General Availability

About You

Education and Experience

Current or Most Recent Employer Information?

Criminal History Information

Refrences

Previous Volunteer Experience

Religion + Spiritual Belief

Position on Pregnancy Options