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ROP APPLICATION
Directions: Please Print Legibly

Name: __________________________________________
Ayala Diana M. ____________________
March 21, 2018
(Last) (First) (Middle) Date

Present mailing address:___________________________________________________________

864 La Jolla Way
(P.O. Box or Street Number)

Merced CA 95348
_______________________________________________________________________________
(City) (State) (Zip Code)

( 209 ) 756-9437 ( 209 )____________________

947-8100 ____________________________
dayala104427@muhsdstudents.org
(Telephone Number) (Alternative Telephone Number) (Email Address)

Position applied for:_______________________________________________________________

nursing aide

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

CPR/first aid, knowledge of vital signs, medical terminology, blood borne pathogens training, HIPAA
training, OSHA training, patient transfers, 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 Driver’s License?

‰ No
✔ ‰ Yes _______________________
(Number)

RECORD OF EDUCATION
Course of
study or Last year Did you Diploma
Name of School City/State major completed graduate? or degree
High School 1 2 3✔ 4 general
Merced High School Merced, CA general Pending
June 2018
College/ 1 2 3 4
University Merced College Merced, CA nursing n/a n/a

Other
1 2 3 4
(Specify) n/a n/a n/a n/a n/a

List appropriate extracurricular activities, clubs, organizations and courses for this position:

Child Development, volunteer at Mercy Medical Center. Courses: ROP Medical Technologies, Spanish.

FULL TIME
AVAILABILITY ✔ PART TIME

SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

n/a after 3:30 p after 3:30p n/a after 3:30p after 3:30p 8:00a -
RECORD OF EMPLOYMENT: (Begin with your most recent job)

Period of Employment Job Title and Duties Performed Company Name, Address, and Phone Number
From: To:
nursing aide
Title__________________________Last Intern
Salary: _____________
Family Care, Mercy Medical Center
_________________________________________________
01/18
______ current
______
Mo / Yr Mo/Yr
Duties
315 E. 13th St.
_________________________________________________
0
Total ____Yrs. 3
________Mo.
Vital signs, filing, patient histories, patient transfers, Merced, CA, 95348
_________________________________________________
5
Hours Per Week:_________ patient education,etc.
Reason For Leaving: (209) 564-4500
_________________________________________________
n/a
Supervisor’s Name: _________________________________________________
Mrs. April Brewer, RN
_____________________________________________________

From: To:
$20.00/day Various
babysitter
Title__________________________Last Salary: _____________ _________________________________________________
01/18
______ current
______
Mo/ Yr Mo/Yr Duties:
864 La Jolla way
_________________________________________________
0
Total ____Yrs. 3
________Mo. Merced, CA 95348
Responsible for the health and safety of 2 children, _________________________________________________
4
Hours Per Week:_________ ages 1 and 8. Playing with children, feeding the
Reason For Leaving: kids, _________________________________________________

n/a _________________________________________________
Supervisor’s Name:
Various
________________________________________________

From: To:
TA
Title___________________________Last volunteer
Salary: ____________
Merced High School
_________________________________________________
08/17
______ 07/18
______
Mo /Yr Mo/Yr Duties:
205 W Olive Ave.
_________________________________________________
1
Total ____Yrs. 0
________Mo. Grade papers, enter in computer, passing out Merced, CA 95340
_________________________________________________
n/a
Hours Per Week:_________ papers, collecting them as well. (209) 325-1000
Reason For Leaving: _________________________________________________

school _________________________________________________
Supervisor’s Name:
Tony Gonzales
________________________________________________

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

Name Complete Address (Include City, State, Zip) Phone Occupation_______
1.
Jerry Fragasso 2121 E. Childs Ave.
(559) 917-8148
ROP Instructor
Merced, CA 95341
________________________________________________________________________________________________________________________________

2. Miranda Andrade 728 Nicklaus Ct. (209) 617-6258

Nurse
Atwater, CA 95301
________________________________________________________________________________________________________________________________

3. 205 W. Olive Ave. (209) 325- 1000

Tony Gonzales
Teacher
Merced, CA 95340
________________________________________________________________________________________________________________________________

I authorize investigation of all statements contained in this application.

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

Date:_________________________Signature:_________________________________________________________________

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