Student Application

"*" indicates required fields

Name*

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code

Cell Phone

Home Phone

Email*

Are you at least 18 years of age?*

Yes

Tennessee regulations require that you must be at least 18 years old to attend the Nurse Assistant Program.

Have you ever been convicted of a misdemeanor?*

Yes

Have you ever been convicted of a felony?*

Yes

State the offense, location, date and disposition of each misdemeanor or felony:

Offense

Location

Date

Disposition

Have you ever worked for Memphis Jewish Home & Rehab?

Yes

List date(s) and positions:

Dates

Positions

Have you previously been employed under name or alias?

Yes

List the name or names you used:

Names

How did you hear about this program at MJHR?

Describe any specialized training you have that you believe is relevant to the Nursing Assistant Program.

Education

High School:*

Major Field of Study / Degree

# Years Completed

Did You Graduate?*

Yes

Other:

Major Field of Study / Degree

# Years Completed

Did You Graduate?

Yes

Trade School:

Major Field of Study / Degree

# Years Completed

Did You Graduate?

Yes

Work Experience

List your employers in consecutive order beginning with your current or most recent employer. If self-employed, list firm name and provide your business/customer references. If there is no work experience, please indicate with N/A. Note: your present employer will not be contacted.

Employer 1 Name*

Phone*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Nature/Type of Business*

Supervisor Name & Title*

Employed From*

Employed to*

Your Job Title*

Pay Rate: Beginning*

Pay Rate: Ending*

Employer 2 Name

Phone

Address

Street Address City State / Province / Region ZIP / Postal Code

Nature/Type of Business

Supervisor Name & Title

Employed From

Employed to

Your Job Title

Pay Rate: Beginning

Pay Rate: Ending

Consent*

By submitting this form, I certify that I have read, accepted, and agreed to the Non-Discrimination and Consent Form below.

Memphis Jewish Home & Rehab Non-Discrimination and Consent Form

Memphis Jewish Home & Rehab will not discriminate against any individual based on race, color, sex, national origin, age,
religion, marital status, sexual orientation, gender identity, gender expression, military or veteran status, disability,
or any factors prohibited by federal, state, or local laws. No question in this application is intended to secure information
to be used in a discriminatory way.

Certification of Information

I certify that the information I have provided in this application is true and complete to the best of my knowledge,
and I understand that any misrepresentation, falsification, or omission of any fact in this application, my resume, or
other materials I provide is grounds for dismissal from Memphis Jewish Home & Rehab (“MJHR”) Nurse Assistant Program.

Authorization for Information

I authorize any of the persons or organizations referenced in this application to furnish information concerning my previous
employment, education, or other information they may have, personal or otherwise, including the reason for termination of my
employment if applicable, my work performance, abilities, and other qualities pertinent to my qualifications for employment,
and I release all such parties from all liability for any damages arising from furnishing such information to MJHR and/or its
designee.

Processing of Application

I understand that in processing my application for education, MJHR may verify all of the information provided by me. I also
understand that although my application will be given every consideration by MJHR, receipt of my application by MJHR does not
imply that I will be offered acceptance into the MJHR Nurse Assistant Program.

Contingent Offer of Acceptance

I understand that if I receive an offer of acceptance from MJHR, it will be contingent upon my successful completion of MJHR’s
screening process including, but not limited to, receipt of references satisfactory to MJHR.

Drug and Alcohol Screening

I understand that if I am a student of MJHR, I will be required to consent to and successfully pass a screening for alcohol
and/or drugs and to authorize MJHR and/or its designee to conduct a background check. I also understand that if I am a student
of MJHR, I may be required to submit to additional screens for illegal use of drugs and/or testing for alcohol when requested
by MJHR.

Compliance with Policies

If I am a student of MJHR, in consideration of such education, I agree to comply with MJHR’s policies, rules, regulations,
and procedures, as set forth in MJHR’s student handbook, and I acknowledge that these policies, rules, regulations, and procedures
may be changed, interpreted, withdrawn, or added to by MJHR at any time, at MJHR’s sole option without any prior notice to me.

At-Will Participation

If I am accepted into the MJHR Nurse Assistant Program, I understand that if I am a student of MJHR Nurse Assistant Program and
not an employee of MJHR, my participation is at-will and may be terminated with or without cause at any time by me or by MJHR.

By submitting this form, I certify that I have read, accepted, and agreed to the above MJHR conditions.

Name

This field is for validation purposes and should be left unchanged.

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