Champion Home Care Employment form

Name * First Last

Email *

Date of Birth: *

Shift Preferred *

Any Part Time Full Time Days Nights Weekends Weekdays On Call Occasional

Select all that apply.

CNA License Number

CPR EXP. Date

HS Graduate *

Yes No

College

No College 1 year 2 years 3 years 4 years or More

Total Years of Caregiving Experience? *

Most Recent Place of Employement *

Describe Last Job Experience *

Name of Reference 1 *

Name of Reference 2 *

Permissions

I give permission for Champion Homecare to check the references listed above. I also give permission for Champion Homecare to conduct a criminal history check. I understand that CHS has a zero tolerance on the criminal history check. I understand that I will not be employable if my criminal history has any positive findings. I agree that I have been given information and consent to a search by CHS in both the Employee Misconduct Registry and the Nurse Registry before hiring and annually thereafter. I understand that I cannot be employed or continue employement with CHS or any other agency or facility if listed as not employable in the EMR or NAR. Reference to this law is TAC Title 40, Chapter 93, Rule 93.3 and Chapter 253, Texas Health and Safety Code, Employee Misconduct Registry. A facility must search the EMR and NAR annually to determine if an employee is listed on either registry as unemployable. A copy of the results of the searches required by this law will be kept in the person's personnel file. I have been given a copy of CHS drug policy. I agree to comply with testing as required by the policy and requested by the agency. I release CHS and discharge CHS employees, agents and representatives from any claim or liability arising from such tests, including the testing process and procedure, analysis, and disclosure of the results. I voluntarily authorize the release of medical information concerning the results of my drug and/or alcohol tests to company representatives who will use it to determine if I am in compliance with this policy. I also understand that I am entitled to a copy of this authorization. I also understand that refusal by me to sign this consent will cause me to ineligibile for employment at CHS.

By checking this box, I agree with the Permissions section above. *

I agree.

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Permissions