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ROP APPLICATION
Directions: Please Print Legibly
Gomez
Melissa
Sophia
Name: __________________________________________

(Last)

(First)

March 4, 2016
____________________

(Middle)

Date

3235 Nottingham Avenue

Present mailing address:___________________________________________________________

(P.O. Box or Street Number)

California
95340
Merced
_______________________________________________________________________________

(City)

(State)

( 209 ) 628-3545

(Zip Code)

melissag1227@icloud.com
722-9431
( 209 )____________________
____________________________
(Alternative Telephone Number)
(Email Address)

(Telephone Number)

Physical Therapy Aide

Position applied for:_______________________________________________________________

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

BLS/first aide, SOAP notes, knowledge of vital signs, medical terminology, basic pharmacology, bloodborne
pathogens training, HIPAA training, OSHA training, patient transfers, gait training, instruction on usage of
crutches and walkers

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

High School

Name of School

City/State

Course of
study or
major

Merced High School

Merced, CA

General

College/
University

n/a

n/a

n/a

Other
(Specify)

n/a

n/a

n/a

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:
Link Crew, freshman mentor, Dare-2-Care Club, , JV & Varsity Track, Merced Youth Baseball volunteer.
Courses: ROP Medical Technologies, Anatomy and Physiology, Spanish, Chemistry, AP English, Physics,
Algebra 1 & 2, Physical Education.
FULL TIME

AVAILABILITY

PART TIME

SUNDAY

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

SATURDAY

n/a

9:00a-5:00p

9:00a-5:00p

10:00a-6:00p

9:00a-5:00p

9:00a-5:00p

8:00a-5:00p

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
Physical Therapy Aide
Title__________________________Last
Salary: _____________

_________________________________________________

Duties

_________________________________________________

assisting patients in use of walkers/crutches,

transfer patients into bed/wheelchair (with use of
gait belt)

_________________________________________________

Supervisors Name:
Cheryl Rice, PT
_____________________________________________________

_________________________________________________

$20/day
Title__________________________Last
Salary: _____________
Babysitter

_________________________________________________

Duties:

_________________________________________________

watch over children (ages 6-12), assist with needs

(when hungry, tired, in need of restroom),
entertain/play with children

_________________________________________________

To:

Feb 16
______

present
______

Mo / Yr

Mo/Yr

2
Total ____Yrs. ________Mo.

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

From:

Physical Therapy - Inpatient

To:

2013
______

present
______

Mo/ Yr

Mo/Yr

3
Total ____Yrs.
________Mo.
Hours Per Week:_________
10
Reason For Leaving:

Mercy Medical Center

333 Mercy Ave.

Merced, CA 95340

_________________________________________________

564-4260

Judith Benson

1434 W. 25th Street

Merced, CA 95340
(209)-233-5184

_________________________________________________
_________________________________________________

n/a
Supervisors Name:
Judith Benson
________________________________________________
From:

To:

Apr 14
______

Present
______

Mo /Yr

Mo/Yr

1
Total ____Yrs.
________Mo.

10
Hours Per Week:_________
Reason For Leaving:

Merced Youth Baseball

volunteer
Snack Bar Worker
Title___________________________Last
Salary: ____________

_________________________________________________

Duties:

_________________________________________________

snack bar set up/clean up, prepare food, assist

customers with needs (sales)

_________________________________________________

Sports Complex snack bar

1800 block of Wardrobe Avenue

Merced, CA 95341

_________________________________________________

(209)-726-6263

n/a

Supervisors Name:
Trish Cortez
________________________________________________

_________________________________________________

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

Name
1.

Jerry Fragasso

Complete Address (Include City, State, Zip)

2121 E. Childs Ave.

Phone

(599)-917-8148

Occupation_______

ROP Instructor

Merced, CA 95341

________________________________________________________________________________________________________________________________
2. Trish

Cortez

3321 G St., Ste. A

(209)-596-9526
Front Desk: Allstate

Merced, CA 95340

________________________________________________________________________________________________________________________________
3.

Andrew Calzadillas

205 West Olive Ave

(209)-385-6465
Culinary Arts Instructor

Merced, CA 95344

________________________________________________________________________________________________________________________________

I authorize investigation of all statements contained in this application.

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

3/4/2016
Date:_________________________Signature:_________________________________________________________________

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

Revised 7/10