complete application

							Dear Applicant:

We are pleased that you are interested in obtaining employment at Kids Only Home Health.

We know that 100% of what we do and accomplish is done through the efforts of our staff. Because of this, we
look at the recruiting and hirin process as a critical initial step. It is important for you to understand some of the
basic principals of our vision, mission and performance standards so that you can decide if you are genuinely
interested in becoming a team member in this organization. Before you actually complete our application,
please take some time to review the statements below. In doing so, you will learn more about Kids Only Home
Health.

Our Mission:
Our aim is to treat all clients with Care, Compassion and Respect befitting their dignity as human beings.

Our Vision:
To deliver excellence in pediatric home care.

What our staff want in associates:
   A strong team spirit of working together and mutual support
   Honesty, sincerity and respect
   Pride in your profession life work
   Professional and technical ability
   Caring attitude toward clients, caregivers and each other
   Willingness to go above and beyond to insure exceptional client care
   Flexibility and patience
   Strong self-confidence and self-esteem
   Communication skills (listening, understanding, expression)
   Sense of humor
   Positive motivation/attitude toward health care and work
   Balance in your life

If you are still interested in pursing employment after reviewing our mission and vision, please complete the
attached application. We then welcome the opportunity to talk with you about your interests and goals related to
our organization. We are excited about our role in the care of our clients and are looking for enthusiastic people
to join us in our mission. We hope that the thought of being a team member of an organization with this kind of
vision is exciting to you as well.

Sincerely,

The entire Kids Only Home Health staff

__________________________________________________________________________________________
Utah County                         Salt Lake County                    Davis County
801-225-7171                        801-359-5437                        801-359-5437
                                                                                      APPLICATION FOR EMPLOYMENT


We are an Equal Opportunity Employer. We are dedicated to a policy of non-discrimination of employment on any basis including race, age, sex, marital
status, disabilities, creed, color, religion or national origin and intend to comply fully with all applicable Federal and State employment laws.
                PLEASE PRINT CLEARLY AND COMPLETE APPLICATION EVEN IF YOU ATTACH RESUME



Last Name: ______________________________ First Name: _____________________________ Middle Name: _______________
Address: ______________________________________________ Position Applying for: __________________________________
____________________________________________________ Service/Specialty Preferred: ____________________________
Telephone: ______________________________SSN:____________________________ Salary Desired :________________________
Other Phone Contact: ______________________________________ How were you referred: ________________________________
If employed , can you provide proof of U.S. Citizenship or Authorization to legally work in the United States? □ Yes □ No
To assist us in securing employment references, please list other names used: _____________________________________
                                                                                          Job Title and
   Employer Name and Address                      Dates             Hourly Pay            Description of
   (Most current Employer first)                 Employed           Rate/Salary              Duties                     Reason for Leaving

Employer Name:
                                                   From
_______________________ Address:                  M____
____________________________ City,                Y____
State & Zip: ______________________                 To
Supervisor Name & Number
_____________
                                                  M ____
                                                  Y____
___________________________________.

Employer Name:
                                                   From
_______________________ Address:                  M____
____________________________ City,                Y____
State & Zip: ______________________                 To
Supervisor Name & Number
_____________
                                                  M ____
                                                  Y____
___________________________________.

Employer Name:
                                                   From
_______________________ Address:                  M____
____________________________ City,                Y____
State & Zip: ______________________                 To
Supervisor Name & Number
_____________
                                                  M ____
                                                  Y____
___________________________________.


Employer Name:
                                                   From
_______________________ Address:                  M____
____________________________ City,                Y____
State & Zip: ______________________                 To
Supervisor Name & Number
_____________
                                                  M ____
                                                  Y____
___________________________________.

                                                                                           Graduated?              Average            Areas of
           Schools                        Name, City, State of School
                                                                                             (Circle)               Grade           Specialization

                                                                                           Yes        No
High School
                                                                                           Yes        No
College
                                                                                           Yes        No
Graduate School
                                                                                           Yes        No
School of Nursing
                                                                                                Application for Employment
 Professional Registration, License, or Accreditation
                                                                           License/ Registration Number                             State             Expiration Date
                       (Type)




 Driver's License (Required for Job)
 Current automobile insurance
 (Required for Job)

                           Please give any other details of your experience you believe would be helpful in assessing your qualifications.

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

Availability:
Saturdays, Sundays, Holidays & Evenings may be required at times for all employees. Hours that you are available to work (check all that apply):
            Weekdays:                                     Weekends                                           Requested # of hrs per week
            □ Early Mornings (5:00am)                     □ Early Mornings (5:00am)                          □ 30-40 Hours
            □ Mornings (8:00am)                           □ Mornings (8:00am)                                □ 25-30 Hours
            □ Mid-Day                                     □ Mid-Day                                          □ 20-25 Hours
            □ Afternoons                                  □ Afternoons                                       □ 15-20 Hours
            □ Afternoons                                  □ Afternoons                                       □ 5-10 Hours
I will accept:        □ Full-time              □ Part-time
If hired, when would you be available to start work? ______________________________________________
Can you work at least two nights during the week?         □ Yes     □ No
Which nights would you prefer? __________________________________________________________________________________________
Can you work at least every other weekend? □ Yes □ No; Why not? _________________________________________________________
Are you willing to participate in an on-call rotation? □ Yes □ No; Why not? _____________________________________________________
____________________________________________________________________________________________________________________________________

Have you ever been convicted of a felony within the last seven years? □ Yes        □ No
If yes, what charge? _______________________________________ (a conviction will not necessarily bar you from employment).

Have you been ticketed with more than two moving violations in the last three year? □ Yes □ No
If yes, please explain: ____________________________________________________________________________________________________

May we contact your present employer?      □ Yes □ No

All offers of employment at Kids Only Home Health will be contingent upon proof of identity and verification of eligibility for employment in the United States, in
accordance with the Immigration Reform and Control Act of 1986.
            1.          I understand that Kids Only Home Health provides a smoke free environment for its employees and clients. I do not use illegal drugs and am
                        willing and able to maintain compliance with this policy.
            2.          I freely and voluntarily agree to random drug testing. I understand that refusal to take this test or positive test results will be grounds for
                        dismissal.
            3.          I understand that I may be asked to submit documentation supporting the following:
                                    a.) Transcripts (Official and unofficial), certificate or diploma, or other official statements or documents supporting post high school
                                    education and training.
                                    b.) Copies of appropriate professional or vocational licensure, certification, or registration.
                                    c.) Current Utah driver’s license and proof of current automobile insurance.
                                    d.) For clerical positions: verification of typewriting and/or spelling scores from Job Service, if specified.
                                    e.) For contract personnel, proof of current malpractice insurance, if specified.
            4. I give permission to Kids Only Home Health to:
                                    a.) Contact all references and former employers except those specifically indicated by a “NO” in the employment history portions of
                                    this application.
                                    b.) Investigate all statements made and implied in the application including criminal background and driving record. I understand that
                                    I may omit any information that I feel is discriminatory in nature.
                                    c.) Require that I take one or more validated and job related tests. I understand that a job offer may be suspended or withdrawn
                                    pending test results.
____________________________________________________________________________________________________________________________________
I herby certify that I have read and I do understand these application instructions and terms. I further certify that all statements made in this application are true and
correct to the best of my knowledge. I understand that any falsification or misrepresentation of facts may result in disqualification or dismissal.


Signature: ____________________________________________________________________________________ Date: _______________________________
                                                                                  Application for Employment
Applicant Name: _______________________________________________________________________________________________________
Please list three people that we may contact, other than those listed in your employment history, who are in no way related to you and who you have
known for at least three years.

Reference and Prior Employment Check

                 References                                                      Results of Reference Check

 Name: _______________________
 Telephone: ___________________
 Relationship: __________________
 Years Known: _________________


 Name: _______________________
 Telephone: ___________________
 Relationship: __________________
 Years Known: _________________


 Name: _______________________
 Telephone: ___________________
 Relationship: __________________
 Years Known: _________________



 To be completed by Interviewer

                   Interview                                                               Comments



 1st Interview
 Interviewer: ____________________
 Date: ________________________




 1st Interview
 Interviewer: ____________________
 Date: ________________________