BAS - Patient Care Provider Application

Patient Care Provider Application

NOTE: All communication regarding selection will be exclusively through your email address. Please check your junk/spam folder.
Today's Date*

MonthDayYear
Date
E-mail*
example@example.com
Name*

First NameLast Name
Gender

MaleFemale
Birth Date Must be 18 years old on or before March 9, 2026*

MonthDayYear
Date
Age*
Home Number
Cell Number*
Street Address *
City & State Name*
Zip Code*
What is your birth Country?*
Do you have a valid California ID or California Driver's License?*
Do you have a valid Social Security Number (SSN)?*
What is your home language?
What is your primary language?

Health Information (Optional)

Please let us know about any medical conditions, physical limitations, or other health considerations that may be relevant (e.g., allergies, chronic conditions, mobility restrictions, pregnancy, medication needs, etc.). This information will be kept confidential and added to your student profile in the case of any emergency. If applicable, please list any relevant health information below (optional):
If applicable, please list any relevant health information below (optional):*
Emergency Contact
Please provide the first and last name of your emergency contact.*
Emergency contact's relationship to applicant*
Please provide the contact number for the above Emergency Contact.*
Please enter a valid phone number.
Education
Have you earned your high school diploma or GED?*

YesNo
Please enter the year you graduated from high school or the year you joined your GED. *
In which city did you graduate or earn your GED?*

In which state did you graduate or earn your GED?*
Please provide the name of the school you earned your high school diploma or GED.*
Highest Education Earned

High SchoolAssociatesBachelorsMastersDoctorateCareer Technical Education/ CertificationOther
Are you currently enrolled in any educational programs, schools, classes, or colleges? If yes, please explain.
Have you previously graduated from a BAS Health Careers Program(s)?*
If applicable, please list any health industry certifications you currently possess or any experience in the health industry.
Employment Information
Are you currently employed?*

YesNo
Where are you currently employed?
What is your current position/job title?

Professional Reference

If not applicable, please type N/A
Professional Reference Full Name*
Title/Position*
Phone*
Professional Reference Full Name*
Title/Position*
Phone*
Professional Reference Full Name*
Title/Position*
Phone*

Disclaimer

The Kern High School District (KHSD) is committed to ensuring equal, fair, and meaningful access to employment and education services. KHSD prohibits discrimination, harassment (including sexual harassment), intimidation, or bullying in any employment practice, education program, or educational activity on the basis and/or association with a person or group with one or more of these actual or perceived characteristics of age, ancestry, color, ethnic group identification, gender, gender identity or expression, genetic information, immigration status, marital status, medical information, national origin, physical or mental disability, parental status, political affiliation, pregnancy and related conditions, race, religion, retaliation, sex, sexual orientation, military or veterans status, homelessness, foster status, affiliation with the Boy Scouts of America and other designated youth groups, or any other basis prohibited by California state and federal nondiscrimination laws consistent with Education Code 200 and 220, Government Code 11135, and Title IX. If you believe you have been subjected to discrimination, harassment (including sexual harassment), intimidation, or bullying you should contact your school site principal and/or the District's Equity Compliance/Title IX Officer, Melissa Jimenez, 5801 Sundale Avenue, (661) 827-3173, titleix@kernhigh.org, Title II/ADA Officer, SELPA Director Special Education, Greg Hicks 5801 Sundale Avenue, (661) 827-3105, greg_hicks@kernhigh.org, and Section 504 Coordinator, Elaine Gregory, 5801 Sundale Avenue, (661) 827-3288, elaine_gregory@kernhigh.org. A copy of KHSD's Uniform Complaint policy and Nondiscrimination policy are available at www.kernhigh.org and upon request..
I have read the Disclaimer above*

Yes
Date:*

MonthDayYear
Date
Signature:*

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