ROP APPLICATION

Directions: Please Print Legibly

Lawrence
Joshua
Russell
Name: __________________________________________

(Last)

(First)

28 April 2015
____________________

(Middle)

Date

569 Leslie ct.

Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

CA.
Merced
95348
_______________________________________________________________________________

(City)

(209 ) 777-3561
(Telephone Number)

(State)

(Zip Code)

joshualawrence840@yahoo.com
722-4377
( 209 )____________________
____________________________
(Alternative Telephone Number)
(Email Address)

Position applied for:_______________________________________________________________

Nursing Assistant
Skills and/or competencies which qualify you for this position:
Experienced in first aid, CPR, vital signs, discharging patients, and interacting with the families of patients.

NA
Languages spoken and/or written (other than English):___________________________________

Have you ever been convicted, pleaded guilty or no contest to a misdemeanor or felony?
No

Yes

If yes, explain:________________________________

Do you possess a valid California Drivers License?

No

Yes

_______________________
(Number)

RECORD OF EDUCATION

Name of School
High School

City/State

Merced High School

Course of
study or
major

Last year
completed

Did you
graduate?

Diploma
or degree

diploma

1 2 3 4

June 2015

Diploma

Merced, CA.

College/
University

1 2 3 4

Other
(Specify)

1 2 3 4

List appropriate extracurricular activities, clubs, organizations and courses for this position:
MHS Link Crew, Mercy Medical Center student volunteer, Mercy Medical Center nursing aide, Merced High
School Library Assistant, cross country team, and track team
FULL TIME

AVAILABILITY

PART TIME

SUNDAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

Yes

Yes

Yes

Yes

Yes

Yes

Yes

RECORD OF EMPLOYMENT: (Begin with your most recent job)

Period of Employment
From:

Job Title and Duties Performed

Company Name, Address, and Phone Number

Volunteer
Student Volunteer
Title__________________________Last
Salary: _____________

_________________________________________________

Duties

_________________________________________________

Discharging patients, writing visitor passing,

washing dishes, and running errans for staff

_________________________________________________

To:

Feb 2012
______

April 2015
______

Mo / Yr

Mo/Yr

2
3
Total ____Yrs.
________Mo.
4
Hours Per Week:_________
Reason For Leaving:
This is a high school
program. I will graduate in
June.
From:

333 Mercy Ave. Merced, CA. 95340

March 2015
______

Mo/ Yr

Mo/Yr

6
Total ____Yrs. ________Mo.
Hours Per Week:_________
3
Reason For Leaving:

(209)564-5000

_________________________________________________
Supervisors Name:
Jan Sorge
_____________________________________________________

_________________________________________________

$99
Title__________________________Last
Salary: _____________
Student Library Assistant

_________________________________________________

Duties:

_________________________________________________

wiping tables, stocking textbooks, shelving library

books, watering plants, and stamping book cards

_________________________________________________

To:

Sept. 2014
______

Mercy Medical Center

Merced High School

205 W. Olive Ave. Merced, CA. 95348

(209)385-6490

_________________________________________________

Wanted to focus on studies

_________________________________________________
Supervisors Name:
Sarah Morgan
________________________________________________

From:

To:

Feb. 2015
______

May 2015
______

Mo /Yr

Mo/Yr

4
Total ____Yrs. ________Mo.

Mercy Medical Center

Volunteer
Nursing Aid
Title___________________________Last
Salary: ____________

_________________________________________________

Duties:

_________________________________________________

Taking vital signs and giving patients water

_________________________________________________

333 Mercy Ave. Merced, CA. 95340

5
Hours Per Week:_________
Reason For Leaving:

(209)564-5000

_________________________________________________

Supervisors Name:
Rachel Abryl
________________________________________________

_________________________________________________

REFERENCES: Give the names of three persons not related to you.

Name
1.

Sarah Morgan

Complete Address (Include City, State, Zip)

205 W. Olive Ave. Merced, CA. 95348

Phone

Occupation_______

(209)385-6490
Librarian

________________________________________________________________________________________________________________________________
2. Jan

Sorge

333 Mercy Ave.

(209)769-1884
Volunteer Advisor

Merced CA. 95340

________________________________________________________________________________________________________________________________
3. Gerald

Fragasso

2121 E Childs Ave.

(559)917-8148

Merced, CA. 95341

ROP Teacher

________________________________________________________________________________________________________________________________

I authorize investigation of all statements contained in this application.

I understand that misrepresentation or omission of facts is cause for dismissal.

Date:_________________________Signature:_________________________________________________________________