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Speech Pathologist
SLP Assistants
Clinical Fellow CFY
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Contact
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Patient Coordinator Application
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Phone
Address
Address Line 1
Address Line 2
City
--- Select state ---
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State
Zip Code
Email
*
Are you at least 18 years of age?
*
Yes
No
Date of Birth
*
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Are you legally authorized to work in the US?
*
Yes
No
Are you fluent in any languages other than English?
*
Yes
No
Which language?
Do you have a valid CPR certification? (copy)
*
Yes
No
Do you have reliable transportation with insurance?
*
Yes
No
Are you willing to take a drug test and background screening?
*
Yes
No
Highest Level of Education (Completed)
*
High School
Bachelors
Masters
Doctorate
School / College / University Attended
Years Attended
Additional Comments
Upload Resume and/or Cover Letter
*
Click or drag files to this area to upload.
You can upload up to 2 files.
Upload CPR Certification
Click or drag files to this area to upload.
You can upload up to 2 files.
Please enter the name and phone number for three professional references:
*
Candidate Consent Agreement
*
I Agree to the Candidate Consent Agreement
I Decline the Candidate Consent Agreement
By agreeing above, I confirm that the information I provide on this application is accurate and true
to the best of my knowledge. I agree to include all of my years of experience on my completed
application and attachments. I also authorize the organization to consider my application for other
similar open position(s) for which I meet the minimum qualifications. Should a position be offered
and it is determined that the information is untrue or misrepresented, I understand and agree that
the facility or its affiliate(s) does not have any obligation to hire me for the position offered and/or
I am subject to discharge from employment. I also represent that I am not subject to any
debarment, exclusion, or other event that makes me an ineligible person to participate in any
Federal healthcare program or receive a government contract.
I am granting permission to the organization to use my personal mobile phone number and
personal email address (e.g., gmail.com, outlook.com) to send communications (e.g., emails,
prerecorded voice message calls, and text messages) for purposes related to the application and
interview process, my candidacy for a new position, new hire/onboarding process, my position and
role with the company, access to company systems and applications, and other pre-hire and/or
job-related communications. Example purposes of these communications include maintaining my
organization’s accounts (e.g., setting my initial password, unlocking my account, or resetting my
password), authenticating my log-in requests where multi-factor is required validating my identity
when contacting the organization’s service desk, and as a means of communicating information
relevant to my employment and/or workplace. Since this option is offered for my convenience, I
understand that I am responsible for any costs that my mobile service provider may charge to
receive these communications. I understand that if I am a non-exempt employee, the use of
organizational services, such as the Identity Connect portal, must be performed during working
hours and no work should ever be performed off-the-clock. Except as necessary to support the
organization’s tools, the organization will not share my mobile phone number or personal email
address with third parties. I understand that this permission is optional, and if I am unable or
unwilling to provide my personal mobile phone number and/or personal email to perform job-
related functions, such as those related to maintaining my organization’s accounts or
authentication. I also understand it is my responsibility to notify the company if I want to utilize
the alternate option or if my information changes.
Submit