Employee Information FormPhoenix House requires that all onboarding employees complete this form as a condition of their employment. Full Legal Name * First Name Last Name Preferred Name (what your coworkers will call you) Date of Birth * MM DD YYYY Email * Phone * (###) ### #### Driver's License Number, State Issued, and Expiration Date * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact * Full name, phone number, and relationship to employee Marital Status * Single Married Domestic Partnership In a Civil Union Seperated Divorced Widowed Prefer Not Disclose Medical History & Health Information Do You Currently Have Health Insurance Coverage? Yes No Do You Want Health Insurance Through Phoenix House? Yes No Not sure, I'd like to discuss my options. Did you receive the MMR and TDAP vaccines at some point in your life? * Yes No Not Sure Do you get an annual flu shot? * Note, the flu shot is NOT required as a condition of employment with Phoenix House, however, a written declaration stating that you do not get your flu shot is required. Do you have any known allergies? * Do you have any food intolerances? * Chronic Medical Conditions * Disclosure is optional, unless a condition has the potential to impact the safety of the children in your care (i.e. epilepsy, frequent fainting, blood glucose disorders, etc.) Medications Taken Regularly Disclosure is optional, for emergency preparedness only. Physical Restrictions or Accommodations Needed Thank you!