Clone of FISH Employment Application

FISH MD Employment Application

Thank you for your interest in becoming an employee at the Faith in Serving Humanity Ministry (FISH).
Employment Application
FISH MD Clinical Staff – Adult Medicine (RN / LPN / MA / EMT)

FISH MD is seeking a licensed healthcare professional (RN, LPN, MA, or EMT) with experience in adult medicine for a full time position.

Responsibilities will include:
- direct patient care
- obtaining vital signs and patient histories
- administer medications and treatments
- performing EKGs and blood draws
- providing wound care
- educating patients about chronic disease management and preventive care
Additional duties include coordinating care with healthcare providers, maintaining patient records, and supervising support staff as needed.
Please upload your resume with the link provided at the end of this application.
Full Name

First NameMiddle NameLast Name
Current Address

Street Address

Street Address Line 2

CityState

Zip Code
Email Address
Phone #

Area CodePhone Number
If hired, can you provide evidence of legal eligibility to work in the U.S.? Please note that any offer of employment is conditioned upon completing form I-9 and providing the appropriate documents for identity and work authorization.

Did you attend college or technical school?
Name of college or technical school attended
College or technical school location (city and state)
Did you graduate from a certified medical program?
What medical licenses or certifications do you currently hold?

Work Availability and Job-related Skills
Date available

MonthDayYear
Please share your professional medical experience, for example, working as a nurse or doctor in a hospital, experience in a medical office, or working as a health educator with patients.
What other special gifts, skills, or experience do you have that you could use while working at the FISH MD medical clinic? (Strong communication skills, excellent rapport with patients, organizational skills, working well with other staff)

Employment
Current or most recent employer.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Start and end dates of your employment
Job title
Description of duties
Hourly pay or yearly salary
Reason for leaving
2nd most recent employer.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Start and end dates of your employment
Job title
Description of duties
Hourly pay or yearly salary
Reason for leaving

Reference

Not former employers who we can contact.
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
How long have you known this person?

Carefully read this statement before checking "I understand and agree" at the bottom: I certify that all the information provided in this employment application are true and complete to the best of my knowledge, and I authorize investigation of all statements contained in this application, including a criminal background and credit history check. I understand that any false or incomplete information may disqualify me from further consideration for employment and may result in my immediate discharge if discovered at a later date. I understand and acknowledge that, unless otherwise defined by applicable law or written agreement with Faith In Serving Humanity, any employment relation with the Faith In Serving Humanity is considered "employment at will". This means the Employee may resign at any time and the Employer may discharge the Employee at any time, with or without cause, and with or without advance notice. I authorize the investigation of any and all statements contained in this application and also authorize any person, school, current employer, past employers, and other organizations to provide information concerning my previous employment and other relevant information that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements.
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CONFIDENTIALITY & NON-DISCLOSURE AGREEMENT

I acknowledge that in connection with my duties as a staff member or a volunteer for Faith In Serving Humanity (F.I.S.H.), FISH-MD or FISH 4 KIDS, I may gain access to the demographic information, and personal health information, (as defined herein) of patients/clients to be serviced through the clinic, or families in need of assistance through the ministry, which is required by law to be kept confidential. For and in consideration of my participation in the ministry and/or clinic, I agree as follows:
1. Demographic Information refers to information that identifies an individual (name, address, telephone number, etc.).
2. Personal Health Information relates to past, present or future physical or mental health conditions, or any other information disclosed by a patient/client or discussed with a patient/client regarding the provision of services provided through the ministry and/or clinic
I understand that the ministry and/or clinic’s leadership expects me to hold in confidence and not disclose, directly or indirectly, any personal information, or any portion thereof, communicated, discussed, delivered, or made available by any patient/client. I acknowledge that my obligation under this Agreement remains in effect indefinitely. I will take reasonable precautions to ensure that the confidentiality of each patient’s/client's personal information is maintained and will follow all ministry and/or clinic procedures in that regard. The ministry’s and/or clinic’s policy is to safeguard access to personal information by taking reasonable steps to maintain its security. I will not discuss personal information in public places or outside of the ministry buildings or clinics. As a representative of FISH, FISH-MD, and FISH 4 KIDS, I acknowledge that I may disclose personal information only to volunteers or to authorized advisors and consultants of the ministry and clinic who have a specific need to know such information in order to serve the patient/client.

I also understand that the Health Insurance Portability and Accountability Act (HIPAA), as established by the Department of Health and Human Services, requires that all clinic personnel maintain the privacy of all patient health information obtained in confidence. The HIPAA law, passed in 1996, provides every patient with the right to privacy regarding their health information.
By typing your name below and clicking "Submit," you acknowledge that you have read, understood, and agree to the Faith in Serving Humanity Confidentiality and Non-Disclosure Agreement. You agree that your typed name constitutes your electronic signature and is the equivalent of your handwritten signature.
Date

MonthDayYear
Date

FAITH IN SERVING HUMANITY
CODE OF CONDUCT FOR STAFF AND VOLUNTEERS

The mission statement of FISH:
Because Jesus Christ calls His believers to be in service to the poor and needy among us, F.I.S.H endeavors to respond to the Spiritual, physical, and financial needs of Walton County residents.

The mission statement of FISH4Kids:
Because Jesus Christ calls His believers to be in service to the poor and needy among us, FISH4Kids endeavors to provide each at-risk child of Walton County an opportunity to succeed.

The mission statement of FISH MD:
Because Jesus Christ calls His believers to be in service to the poor and needy among us, F.I.S.H. MD endeavors to respond to the Spiritual and health needs of Walton County residents.

Ephesians 4:32
Be kind to one another, tenderhearted, forgiving one another, as God in Christ forgave you.

Ephesians 4:1-6
I, therefore, a prisoner for the Lord, urge you to walk in a manner worthy of the calling to which you have been called, with all humility and gentleness, with patience, bearing with one another in love, eager to maintain the unity of the Spirit in the bond of peace. There is one body and one Spirit-just as you were called to the one hope that belongs to your call- one Lord, one faith, one baptism, one God and Father of all, who is over all and through all and in all.

Philippians 4:8-9
Finally, brothers, whatever is true, whatever is honorable, whatever is just, whatever is pure, whatever is lovely, whatever is commendable, if there is any excellence, if there is anything worthy of praise, think about these things. What you have learned and received and heard and seen in me-practice these things, and the God of peace will be with you.

I do hereby understand that in my service at FISH, FISH4Kids, FISH Medical, and Dental, I represent Christ. I will conduct myself in a manner that promotes a positive and joyful attitude. I will pray for FISH, FISH4kids, and FISH Medical and Dental.

I believe and support the mission statements of FISH, FISH4Kids, and FISH Medical and Dental:
By typing your name below and clicking "Submit," you acknowledge that you have read, understood, and agree to the Faith in Serving Humanity Code of Conduct. You agree that your typed name constitutes your electronic signature and is the equivalent of your handwritten signature.
Date

MonthDayYear
Date
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FISH MD Employment Application

Please upload your resume with the link provided at the end of this application.

Work Availability and Job-related Skills

Employment

Reference