Registration: Curry Health Shiftboard

If you have not yet registered for access to our online scheduling system, please complete the following form.

* required field
APPLICANT INFORMATION
 

ADDITIONAL INFORMATION
Emergency Contact
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Relationship
Availability
How soon are you available to start?
Preferences
Location Preference Notes - Areas where you would like to work.
Degree/Certification
Highest Nursing Degree Earned
School Name
School Location

Specialties
Do you specialize in a certain area of nursing or in the medical field?
 Yes  No
List years of experience, special credentials, or certifications you have
Previous Employment Company Name
Previous Employment Supervisor Name
Previous Employment Phone Number
Previous Employment Company Start Date
Previous Employment Company End Date

Previous Employment Company Name (2)
Previous Employment Supervisor Name (2)
Previous Employment Phone Number (2)
Previous Employment Company Start Date (2)
Previous Employment Company End Date (2)
First Reference Name
First Reference Relationship
First Reference Phone

Second Reference Name
Second Reference Relationship
Second Reference Phone

REG
Nursing License
Nursing License Expiration
Eval Date
BLS
ACLS
TNCC
NRP
Stable
PALS
AWHONN
EKG



Thank you for your interest!
 
 
Curry, Oregon 98107
541-247-3126
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