Intensive Care Coordinator, Child and Adolescent Program

Full Time

Available Position(s)

Child and Adolescent Intensive Care Coordinator, Main Center, Selma

Job Description

Requires a bachelor's degree in a Human Services related field and a valid Alabama Driver's License

Prerequisites

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Employment Application

Applicant

First Name

Middle Name

Last Name

Street Address

City

State

Zip Code

Telephone

Email Address

Citizenship

Position Desired

Full Time or Part Time

May we contact your current employer?

When can you begin?

Desired starting salary?

Employment Experience

Start with your present or last job. List all employment experience. Email additional jobs or resume to [email protected].

1

Employer

Date Employed From

Date Employed To

Address

Telephone Number(s)

Job Title

Supervisor

Reason for Leaving

2

Employer

Date Employed From

Date Employed To

Address

Telephone Number(s)

Job Title

Supervisor

Reason for Leaving

3

Employer

Date Employed From

Date Employed To

Address

Telephone Number(s)

Job Title

Supervisor

Reason for Leaving

Education and Training

High School

Name of School

Location

Dates

Graduated?

Degree

Major

College

Name of School

Location

Dates

Graduated?

Degree

Major

College

Name of School

Location

Dates

Graduated?

Degree

Major

Personal Reference

Other than Relatives

1

Name

Address

Telephone Number

2

Name

Address

Telephone Number

Supplemental Information

List any other factors which you feel might be important in your application for employment including typing, office machines used, professional licenses and/or certificates, and any other experience or training not covered in the application elsewhere.

Have you ever been denied coverage under an employee fidelity bond?

Applicants for Clinical Positions:

Have you ever had your professional license suspended or revoked, or have you ever been disciplined by your license board?

Applicants for Positions that Include Driving:

Do you have a medical condition that restricts your driving ability (i.e., Insulin dependent, seizures, sight problems, etc.)?
If yes, please explain:

Affidavit

I certify that the answers given to the foregoing questions are true and correct without consequential ommissions of any kind whatsoever. I understand that any false or misleading statements are grounds for dismissal and shall not hold the Mental Health Center liable in any respect if my employment is terminated because of said falsification or omissions made by me in the questionnaire. I authorize the employers (with the possible exception of current employer), schools or persons named herein to give any information regarding my employment or physical condition, together with any information they may have regarding me whether or not it is in their records. I hereby release said employers, schools, or persons from all liability for any damage for issuing this information. If accepted for employment, I hereby authorize my participation in any group insurance and/or retirement plans for which I am eligible and in which participation is a condition of employment. I further agree to abide by all policies of the Cahaba Center.

Full Legal Name

Date

Note: Any item on this form which you feel tends to violate Federal or State Civil Rights of FEPC Legislations need not be completed. We are an Equal Opportunity Employer. A copy of this application is available to you on request.