Patient Transport Assistant Application
Please complete all sections to apply for the Driver Assistant role and prepare your certifications.
Personal Information
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Street Address
*
City
*
State
*
ZIP Code
*
Date of Birth
*
-
Month
-
Day
Year
Date
Position Information
Position Applying For
*
Employment Type
*
Full-Time
Part-Time
Available Start Date
*
-
Month
-
Day
Year
Date
Preferred Shift
*
Morning
Afternoon
Evening
Flexible
Days Available
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Work Experience
Current Employer
Job Title
Employer Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Reason for Leaving
Describe your experience in healthcare, transportation, or customer service
Patient Care Experience
Do you have experience assisting patients?
*
Yes
No
Have you worked with any of the following?
Wheelchair patients
Stretcher patients
Elderly clients
Dialysis patients
Hospital discharges
None
Do you have experience assisting individuals with limited mobility?
*
Yes
No
Physical Requirements
Are you able to safely lift or assist up to 100 lbs?
*
Yes
No
Are you able to push occupied wheelchairs safely?
*
Yes
No
Are you comfortable assisting patients in and out of vehicles?
*
Yes
No
Are you comfortable working in a physically active environment?
*
Yes
No
Certifications
CPR Certified
Yes
No
First Aid Certified
Yes
No
Upload Certifications
Upload a File
Drag and drop files here
Choose a file
Cancel
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Background & Eligibility
Are you legally authorized to work in the United States?
*
Yes
No
Are you willing to undergo a background check?
*
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
If yes, explain
Professional Standards
Signature
Full Name
*
First Name
Last Name
Digital Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit Application
Submit Application
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