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ROP APPLICATION
Directions: Please Print Legibly
Hood
Aubrianna
Maria
Name: __________________________________________

(Last)

(First)

January 20, 2016

____________________

(Middle)

Date

1255 Laplaya Ct.

Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

California
95348
Merced
_______________________________________________________________________________

(City)

(State)

( 209 ) 756-1464

(Zip Code)

songbird209@yahoo.com
201-9679
( 209 )____________________
____________________________
(Alternative Telephone Number)
(Email Address)

(Telephone Number)

Nursing Aide
Position applied for:_______________________________________________________________

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

BLS/first aid, knowledge of vital signs, medical terminology, basic pharmacology, blood borne pathogens
training, HIPAA training, OSHA training, patient transfers, MS Word, Excel, and medical office skills
including scheduling, phone etiquette, translating, etc.

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

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, volunteer at Mercy Medical Center. Courses: ROP Medical Technologies, Chemistry,
Anatomy and Physiology, Spanish, Cheerleading, Jazz Choir, Biology, Forensics
FULL TIME

AVAILABILITY
SUNDAY

10:am-6pm

MONDAY

TUESDAY

after 3:00pm after 3:00pm

WEDNESDAY

N/A

THURSDAY

after 3:00pm

FRIDAY

after 3:00pm

PART TIME

SATURDAY

1:00-7:00pm

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

Period of Employment
From:

Company Name, Address, and Phone Number

volunteer
nursing aide
Title__________________________Last
Salary: _____________

_________________________________________________

Duties

_________________________________________________

vital signs, filing, patient histories, patient transfers,

patient education, scheduling patients, etc.

_________________________________________________

To:

01/16
______

current
______

Mo / Yr

Mo/Yr

0
2
Total ____Yrs.
________Mo.

5
Hours Per Week:_________
Reason For Leaving:
N/A

From:

Job Title and Duties Performed

333 Mercy Ave.

current
______

Mo/ Yr

Mo/Yr

8
0
Total ____Yrs.
________Mo.
Hours Per Week:_________
12
Reason For Leaving:

Merced, CA 95340

_________________________________________________
Supervisors Name:
Dawn Arnsberg, RN
_____________________________________________________

_________________________________________________

$60.00/day
Title__________________________Last
Salary: _____________
babysitting

_________________________________________________

Duties:

_________________________________________________

Responsible for the health ande safety of 2 young

children, ages 7 and 9. Including cooking meals and
playing with children.

_________________________________________________

To:

7/15
______

Mercy Medical Center

Melissa Asato, RN and Michael Asato, RN

4915 Elm Avenue

Merced, CA 95340

_________________________________________________
_________________________________________________

N/A
Supervisors Name:
Meliss Asato, RN and Michael Asato, RN
________________________________________________
From:

To:

2/16
______

current
______

Mo /Yr

Mo/Yr

0
0
Total ____Yrs.
________Mo.

_________________________________________________

Duties:

_________________________________________________

Secretary/Receptionist

_________________________________________________

Merced, CA 95341

10+
Hours Per Week:_________
Reason For Leaving:

N/A

140 Macready Dr # A

$10/day
Tumble Time
Title___________________________Last
Salary: ____________

(209) 723-8309

_________________________________________________

Supervisors Name:
Liz Falk
________________________________________________

_________________________________________________

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

Name
1.

Gerald Fragasso

Complete Address (Include City, State, Zip)

2121 E. Childs Ave

Phone

(559) 917-8148

Occupation_______

ROP Instructor

Merced, Ca 95341

________________________________________________________________________________________________________________________________
2. Laurie

Mclaughlin

205 W Olive Ave

(209) 385-6465
Anatomy Teacher

Merced, CA 95348

________________________________________________________________________________________________________________________________
3.

205 W Olive Ave

Merced, CA 95348

(209) 385-6465

Forensics 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:_________________________________________________________________
March
4, 2016
3/4/2016

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

Revised 7/10