Home Health Aide Training Application

Please fill out the information as completely as you can. Information that is required will be indicated with an asterisk (*) after the label. If you have any questions, please feel free to call the number above or at left and request the Human Resources department.

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Applicant Information

Items with an asterisk require further explanation which will appear if selected.
You selected Job Fair, please name the location.
You selected UR Medicine Employee, please give their full name.
You selected Vocational Training, please name the program.
You selected Other, please describe the method of referral.

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Personal Information

UR Medicine Home Care is an equal opportunity employer and does not discriminate on the basis of race, creed, color, religion, national origin, citizenship, age, gender, sexual orientation, disability, marital status, veteran status or any other status protected by law.
Previous Contact with UR Medicine Home Care:
This includes; UR Medicine Home Care, Finger Lakes Visiting Nurse Service (FLVNS), Visiting Nurse Service (VNS) or Community Care of Rochester (CCR).
If yes, please select the date of that application.
If yes, please select the last date of that employment.
Employment Eligibility
Availability
Please list hours you are available for each section of the week.

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Tell Us Something ...

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Experience

Starting with your current or most recent employer, list all employment. Please list all information even if attaching a resume.
Most Recent Employer
Previous Employer
Previous Employer
Previous Employer

Military Experience

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Education

High School Information
Training or Nursing School Information
College Information
Graduate School Information
Other Educational Experience

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Work References

Please do not include relatives
First Reference
Second Reference
Third Reference

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Resume Upload

Please take a moment and upload a copy of your resume. The upload software will accept the following file types; PDF, Word (doc, docx), and Open Office (odt) and Text (txt). It will not allow compressed file types.
Maximum filesize is 2mb.

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Consent & Signature

UR Medicine Home Care is an equal opportunity employer.  This organization doesn't discriminate on the basis of race, creed, color, religion, national origin, citizenship, age, gender, sexual orientation, disability, marital status, veteran status or any other status protected by law.

After successful completion of training, an individual is qualified to apply for employment as a Home Health Assistant. UR Medicine Home Care is committed to providing the highest quality service to the community. UR Medicine Home Care is also committed to the safety and comfort of their patients and staff. UR Medicine Home Care therefore reserves the right to solicit information relative to your suitability for the training for which you are being considered. Should you be considered for employment after successfully completing training, the following would be considered in the employment decision: medical clearance including drug testing, driving record, record of felony conviction, finding of patient/resident abuse, work history, and any other pertinent information.

I understand that omissions and/or misrepresentations made on the application form may be cause for my removal from training. I therefore certify that the information contained therein is true and complete to the best of my knowledge.

I further understand that I will not receive any wages, stipends or any other payments until such time as I may be selected for employment following the completion of the training program. I understand that a safe driving record is a requirement for a driving position.