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ROP APPLICATION
Directions: Please Print Legibly
Diaz Esmeralda Yvette
Name: __________________________________________

(Last)

(First)

03/04/16
____________________

(Middle)

Date

123 Childs Ave.

Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

CA
95341
Merced
_______________________________________________________________________________

(City)

(State)

( 209 ) 675-2523

(Telephone Number)

(Zip Code)

esmeralda.diaz81@yahoo.com
)____________________ ____________________________

(Alternative Telephone Number)

(Email Address)

emergency room aide

Position applied for:_______________________________________________________________

Skills and/or competencies which qualify you for this position:

CPR/first aid, knowledge of vital signs, medical terminology, blood borne pathogens training, HIPAA
training, OSHA training, MS word, and bilingual.

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

Spanish
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

City/State

Course of
study or
major

Merced High School

Merced,CA

general

College/
University

Merced College

Merced,CA

nursing

Other
(Specify)

n/a

n/a

n/a

High School

Last year
completed
1 2 3 4

1 2 3 4

1 2 3 4

Did you
graduate?

Diploma
or degree

Pending
June 2016

general

n/a

n/a

n/a

n/a

List appropriate extracurricular activities, clubs, organizations and courses for this position:
Dare-2-Care Club. Courses: ROP Medical Occupations, AP Statistics, English, Anatomy and Physiology,
Chemistry, Biology
FULL TIME

AVAILABILITY
SUNDAY

open

MONDAY

8am-10am

TUESDAY

8am-10am

WEDNESDAY

8am-10am

THURSDAY

8am-10am

FRIDAY

8am-10am

PART TIME

SATURDAY

open

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

Period of Employment
From:

Job Title and Duties Performed

Company Name, Address, and Phone Number

n/a
emergency room aide
Title__________________________Last
Salary: _____________

_________________________________________________

Duties

_________________________________________________

stocking rooms, shadowing nurses, and work with

patients

_________________________________________________

To:

02/16
______

current
______

Mo / Yr

Mo/Yr

0
1
Total ____Yrs.
________Mo.

6
Hours Per Week:_________
Reason For Leaving:
n/a

From:

333 Mercy Ave.

current
______

Mo/ Yr

Mo/Yr

6
0
Total ____Yrs.
________Mo.
Hours Per Week:_________
2
Reason For Leaving:

Merced, CA 95340
(209) 564-5000

_________________________________________________
Supervisors Name:
Phillip Brown, RN
_____________________________________________________

_________________________________________________

n/a
Title__________________________Last
Salary: _____________
Mentor

_________________________________________________

Duties:

_________________________________________________

Share skills and knowledge with students, provides

guidance for students, motivates students

_________________________________________________

To:

08/15
______

Mercy Medical Center

Merced High School

205 W. Olive Ave.

Merced, CA 95348
(209) 385-6465

_________________________________________________
_________________________________________________

n/a
Supervisors Name:
Yer Lawson
________________________________________________
From:

To:

01/14
______

current
______

Mo /Yr

Mo/Yr

2
0
Total ____Yrs.
________Mo.

20
Hours Per Week:_________
Reason For Leaving:

n/a

Patricia Insunsa

various
Babysitter
Title___________________________Last
Salary: ____________

_________________________________________________

Duties:

_________________________________________________

Food prep, house cleaning, supervise child age of

13

_________________________________________________

541 George Dr.

Merced, CA 95341
(209) 752-5758

_________________________________________________

Supervisors Name:
Patricia Insunsa
________________________________________________

_________________________________________________

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

Name
1.

Jerry Fragasso

Complete Address (Include City, State, Zip)

1221 E. Childs Ave.

Phone

(559) 917-8184

Occupation_______

ROP instructor

Merced, CA 95340

________________________________________________________________________________________________________________________________
2. Alex

Muro

205 W. Olive Ave.

(209) 385-6465
Attendance liasion

Merced, CA 95348

________________________________________________________________________________________________________________________________
3.

Laurie Mclaughlin

205 W. Olive Ave.

(209) 385-6465

Merced, CA 95348

Science instructor

________________________________________________________________________________________________________________________________

I authorize investigation of all statements contained in this application.

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

Date:_________________________Signature:_________________________________________________________________

N:\ROP\Charlotte Klock\ROP Forms\Forms\ROP Job Application with availbility back-for fillable.rtf

Revised 7/10