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employee management form

Position Desired
Personal Information
Present Address
Do you have a valid Driver’s License?
Have you ever served in the military?
Do you have the legal right to obtain employment in the United States?
Can you perform the essential functions and responsibilities of the position for which you are applying?
Do you require any special accomodation to perform required duties? If yes, explain:
Have you ever worked for Golden Days Health Services?
Do any of your relatives work for Golden Days Health Services?
List any current licenses, certifications, or registrations required for the position for which you are applying. Include date received.
Have you ever been convicted of any criminal or driving offense(s) other than a minor traffic violation?
If yes, written documentation must be provided about criminal offenses from the clerk of court in the county in which the conviction was made, and about any driving offenses other than minor traffic violations from the motor vehicles office.
You must provide at least three current reference letters and/or the name of individuals with whom a reference interview can be conducted. Please give the full name, mailing address, and phone number of three references who have knowledge of your background and qualifications the field
1:
2:
3:
Education & Skills
Experience
References: Give the names of three persons not related to you to whom you have known at least 1 year
I agree to carry out the designated responsibilities to the best of my ability. I have read the position description. I am aware there is a conditional period of 3 months prior to permanent employment. I certify that I have given true, accurate and complete information on this form to the best of my knowledge. I authorized investigation of statements made in this application and understand that false information may be grounds for denial of my position and/or dismissal if I am employed.

Waiver & Release of Liability

Social Outing Information Form

ALL participants must fill out this NEW waiver which includes language for COVID-19

EMERGENCY CONTACT INFORMATION
Release: I understand and agree that the information contained on this form may be released for statistical purposes, and I agree to the release of information for that limited purpose only. I understand that any release of information in identifiable form must be accompanied by a signed consent form and that the information will not be used as an eligibility determination or affect participation as a recipient unless a law has specifically restricted program participation. I understand that GDSC Programs and Activities does not/will not sell any participant information to anyone.
Waiver & Release of Liability: I understand that participating in any program offered by GDSC Programs & Activities including but not limited to sports, exercise, wellness, health, entertainment, social or travel programs may involve inherent risks and dangers. I also understand that even when reasonable precaution is taken, risk remains inherent and accidents and/or injury can still occur. I acknowledge that I am a willing and voluntary participant in such activities, that I am aware of these risks and accept all responsibility for any damages or personal injury that may occur as a result of my participation. I declare myself to be physically sound and suffering from no condition, impairment, disease, or other illness that would prevent my participation in any programs at GDSC Programs & Activities. I acknowledge that it is my responsibility to monitor my own condition and share pertinent medical information with the staff, should it present an impediment to safe participation in my selected Center activities. Furthermore, I agree should that be the case, that I will cease participation in such activities until such time as I secure and present a signed authorization form from my physician. In addition, the novel coronavirus known as COVID-19 is an extremely contagious virus that spreads easily through person-to-person contact. The risks of COVID-19 are described in information provided by the Massachussets Department of Health and Human Services, at https://www.mass.gov/info-details/eohhs-covid-19-reporting , and the United States Centers for Disease Control and Prevention, at https://www.cdc.gov/coronavirus/2019-ncov, and include severe illness, personal injury, permanent disability, and death. The risk of transmission of and infection from the Covid-19 virus is inherently higher in any area where people congregate or share facilities and cannot be prevented. GDSC Programs & Activities may establish rules and procedures to reduce that risk, which, by signing this Acknowledgment and Release, the undersigned agrees strictly to follow, but GDSC cannot and does not warrant or guaranty the safety of the undersigned when using GDSC’s facilities or programs.
Release, Waiver, and Covenant Not to Sue The undersigned releases and waives any claims or actions against GDSC, and its officers, directors, employees, and volunteers, (the “Released Parties”) from any causes of action, claims, or demands of any nature whatsoever, including, but in no way limited to, claims of negligence, which she/he, or her/his successors, may have, now or in the future, against any of the Released Parties on account of personal injury, property damage, death, or accident of any kind, arising out of or in any way related to the use of the GDSC’s programs, whether that participation is supervised or unsupervised, however the injury or damage occurs, and including without limitation any illness or harm caused by or related to the COVID-19 virus.
The undersigned further acknowledges and certifies that (i) she/he is legally competent to sign and deliver this agreement; (ii) the terms of this agreement are legally binding; and (iii) she/he is signing this agreement, after having carefully read it. I do hereby waive and release any and all rights and claims against The GDSC Programs & Activities, Inc., its employees, agents, volunteers, instructors and independent contractors from any and all liability for personal injuries or property damage resulting from my use of GDSC Programs & Activities’ facilities, participation in travel program and/or programming by my voluntary participation.

Waiver & Release of Liability

Social Outing Information Form

ALL participants must fill out this NEW waiver which includes language for COVID-19

EMERGENCY CONTACT INFORMATION
Release: I understand and agree that the information contained on this form may be released for statistical purposes, and I agree to the release of information for that limited purpose only. I understand that any release of information in identifiable form must be accompanied by a signed consent form and that the information will not be used as an eligibility determination or affect participation as a recipient unless a law has specifically restricted program participation. I understand that GDSC Programs and Activities does not/will not sell any participant information to anyone.
Waiver & Release of Liability: I understand that participating in any program offered by GDSC Programs & Activities including but not limited to sports, exercise, wellness, health, entertainment, social or travel programs may involve inherent risks and dangers. I also understand that even when reasonable precaution is taken, risk remains inherent and accidents and/or injury can still occur. I acknowledge that I am a willing and voluntary participant in such activities, that I am aware of these risks and accept all responsibility for any damages or personal injury that may occur as a result of my participation. I declare myself to be physically sound and suffering from no condition, impairment, disease, or other illness that would prevent my participation in any programs at GDSC Programs & Activities. I acknowledge that it is my responsibility to monitor my own condition and share pertinent medical information with the staff, should it present an impediment to safe participation in my selected Center activities. Furthermore, I agree should that be the case, that I will cease participation in such activities until such time as I secure and present a signed authorization form from my physician. In addition, the novel coronavirus known as COVID-19 is an extremely contagious virus that spreads easily through person-to-person contact. The risks of COVID-19 are described in information provided by the Massachussets Department of Health and Human Services, at https://www.mass.gov/info-details/eohhs-covid-19-reporting , and the United States Centers for Disease Control and Prevention, at https://www.cdc.gov/coronavirus/2019-ncov, and include severe illness, personal injury, permanent disability, and death. The risk of transmission of and infection from the Covid-19 virus is inherently higher in any area where people congregate or share facilities and cannot be prevented. GDSC Programs & Activities may establish rules and procedures to reduce that risk, which, by signing this Acknowledgment and Release, the undersigned agrees strictly to follow, but GDSC cannot and does not warrant or guaranty the safety of the undersigned when using GDSC’s facilities or programs.
Release, Waiver, and Covenant Not to Sue The undersigned releases and waives any claims or actions against GDSC, and its officers, directors, employees, and volunteers, (the “Released Parties”) from any causes of action, claims, or demands of any nature whatsoever, including, but in no way limited to, claims of negligence, which she/he, or her/his successors, may have, now or in the future, against any of the Released Parties on account of personal injury, property damage, death, or accident of any kind, arising out of or in any way related to the use of the GDSC’s programs, whether that participation is supervised or unsupervised, however the injury or damage occurs, and including without limitation any illness or harm caused by or related to the COVID-19 virus.
The undersigned further acknowledges and certifies that (i) she/he is legally competent to sign and deliver this agreement; (ii) the terms of this agreement are legally binding; and (iii) she/he is signing this agreement, after having carefully read it. I do hereby waive and release any and all rights and claims against The GDSC Programs & Activities, Inc., its employees, agents, volunteers, instructors and independent contractors from any and all liability for personal injuries or property damage resulting from my use of GDSC Programs & Activities’ facilities, participation in travel program and/or programming by my voluntary participation.

GOLDEN DAYS CIRCLE SOCIAL TRIPS

Social Outing Information Form

Our goals are to:
offer services that will help preserve an elder's health, safety, and quality of life; while at the same time allowing them to maintain their independence and dignity.
By signing this document, You agree to Golden Days Circle’s policy that all protected health information, including demographic and contact data, collected and maintained by GDC as necessary and healthcare operations purposes; and will not misuse or inappropriate disclosure of your protected health information.