Where Positive Behavior Grows By Leaps And Bounds

Employment Form

A Haven For Kids, Inc., Inc. dba Positive Leaps, is an equal opportunity employer and upholds the principles of equal opportunity employment. It is the policy of A Haven For Kids, Inc., Inc. to provide employment, compensation and other benefits related to employment based on qualifications and performance, without regard to race, color, religion, national origin, age, sex, veteran status or disability, or any other basis prohibited by federal or state law. As an equal opportunity employer, A Haven For Kids, Inc., Inc. intends to comply fully with all federal and state laws and the information requested on this application will not be used for any purpose prohibited by law. Disabled applicants may request any needed accommodation. This application is intended to allow you, the applicant, to provide A Haven For Kids, Inc., Inc. with the information and data so that your suitability and qualifications can be fairly determined for the position(s) for which you are applying. Please complete this application and answer all questions completely.

* indicates required information

* First Name:

MI:

* Last Name:

* Phone Number:

* Email Address:

* Street Address:

* City:

* State:

* Zip:

* Have you been previously employed by A Haven For Kids, Inc?

Yes

If "Yes", when?

In what capacity?

Employment Desired

What position are you applying for:

Therapist

Child Behavior Aide

Are you applying for Full or Part-time employment:

Full Time

Part Time

If "Part-time", number of hours desired:

Date available to start:

Salary requested:

Personal History

* Are you a United States citizen or do you have an entry permit which allows you to lawfully workin the U.S.:

Yes

Visa Type:

Immigration No.:

* Are you at least 18 years old?

Yes

* Are you ineligible to be employed with a Ohio licensed health care entity as a result of being found guilty by a court of law for abusing, neglecting, or mistrearting individuals in a health care related setting?

Yes

If "Yes", please explain?

* Are you able to perform all of the duties required by the position for which you are applying, without endangering yourself or compromising the safety, health, or welfare of the Children, Adult Clients or other Staff Persons?

Yes

If "No", please explain?

Education

High School:

Graduation Date:

College:

Graduation Date:

Course of Study / Degree Issued:

Other:

Graduation Date:

Course of Study / Degree Issued:

Professional Licensure / Certification / Registration Numbers

* Type of Licenses/Certifications & Registration Numbers

Skills:

List any special skills or qualifications which you posses and feel are relevant to health care and the position for which you are applying. List CPR and First Aid Certification. THERAPISTS: Please list NPI and CAQH numbers

Employment History

Please give accurate and complete information. Start with present or most recent employer.

* May we contact and communicate with your present employer?

Yes

* Employer #1:

* Address:

* Telephone No.:

* Start Date:

End Date:

Name of Supervisor:

Starting Pay:

Ending Pay:

Position and Responsibilities:

Reason for Leaving:

Employer #2:

Address:

Telephone No.:

Start Date:

End Date:

Name of Supervisor:

Starting Pay:

Ending Pay:

Position and Responsibilities:

Reason for Leaving:

Employer #3:

Address:

Telephone No.:

Start Date:

End Date:

Name of Supervisor:

Starting Pay:

Ending Pay:

Position and Responsibilities:

Reason for Leaving:

Military Service

Branch:

Date (Start):

Date (End):

What were your duties:

Did you receive any specialized training:

Yes

If "Yes", describe:

Personal References

Names of friends or relatives, if any, currently employed by A Haven For Kids, Inc.

Name:

Address:

Phone:

Name:

Address:

Phone:

Professional References

Names of 3 Professional References we may contact for a reference.

Name:

Address:

Phone:

Reference Letter

Name:

Address:

Phone:

Reference Letter

Name:

Address:

Phone:

Reference Letter

Please read the following statements completely and carefully before you initial and sign your name.

The Applicant HEREBY CERTIFIES that the answers given on this Application For Employment, including any statements or answers provided by the Applicant during interview, are true and correct. The Applicant fully authorizes A Haven For Kids, Inc., Inc. to contact any references, past and present employers, persons, schools, law enforcement agencies and any other sources of information which may be relevant to the Applicant and this Application For Employment. It is understood and agreed that any misrepresentation, false statement, or omission by the Applicant will be sufficient reason for rejection of the Application For Employment or for dismissal from employment at any time, without recourse or liability to A Haven For Kids, Inc., Inc.

* Initial Here:

The Applicant is hereby informed that the State of Ohio is deemed as an employment-at-will state. The A Haven For Kids, Inc. is a Ohio employer; therefore, the Ohio employment-at-will statutes and rules will apply to the employment status of all A Haven For Kids, Inc. Staff. Thus, no representative of the A Haven For Kids, Inc., Inc. has the authority to enter into any agreement for employment for any specified period of time and that A Haven For Kids, Inc., Inc. is not guaranteeing employment for anyone. No employment contract is created by virtue of the Applicant being hired by A Haven For Kids, Inc., Inc.

* Initial Here:

If employed, the Applicant agrees to fully abide by all Staff Conduct And Workplace Standards, including professional ethics, safety rules, and a code of conduct for the A Haven For Kids, Inc., Inc. The Applicant understands that the A Haven For Kids, Inc. is committed to maintaining a alcohol and drug-free workplace. The Applicant is informed that the A Haven For Kids, Inc. requires employment physical exams with various safety screenings including a drug test as a part of the hiring process. Also, if employed, the Applicant realizes that A Haven For Kids, Inc. conducts random drug testing of its employees.

* Initial Here:

The Applicant is informed that this Application will remain on file for 90 days for consideration. After 90 days, if the Applicant remains interested in a position with A Haven For Kids, Inc., Inc., it will be necessary for the Applicant to recontact A Haven For Kids, Inc., Inc.

* Type Your Name:

* Date:

Attach Resume & Cover Letter

Resume

Cover Letter