Kids Developmental Clinic

KDT Employment Application

Please Note: You must also enter a time in the date/time field or the form will give an error.

* Required

Date

First Name*

Last Name*

Email Address

Address

Street Address

Address Line 2

City

State

ZIP Code

Home phone

Cell Phone

Referred By

Position
Occupational Therapist
Physical Therapist
Speech Therapist
Assistant
Therapy Technician
Front Office

Specialty
Physical Therapy
Occupational Therapy
Speech Therapy
Other

Location
Home Health
Southwest
West
North
Pasadena

General Information

Name of High School

Name of College/University

Degree Earned

Name of College/University

Degree Earned

Special Training and Skills

Pediatric Therapy Experience

Clinic Experience

Former Employers

Employer 1 Name

Employer 1 Position

Employer 1 Salary

Employer 1 Employed From

Employer 1 Employed To

Employer 2 Name

Employer 2 Position

Employer 2 Salary

Employer 2 Employed From

Employer 2 Employed To

Employer 3 Name

Employer 3 Position

Employer 3 Salary

Employer 3 Employed From

Employer 3 Employed To

Employment References

Name - Reference #1

Phone

Professional Relationship

Name - Reference #2

Phone

Professional Relationship

Name - Reference #3

Phone

Professional Relationship

Attach File (250Mb Limit *)*

If you have any issues with completing this form or if you recieve an error in trying to submit. Please send your resume and information by email to info@kidsdevelopmentaltherapy.com or call 713-668-6690

Kids Developmental Therapy does not discriminate against any person on the basis of race color religion or national origin disability or age in admission treatment or participation in programs services and activities or in employment. Kids Developmental Therapy complies with the standards for privacy of patient information required by the Health Insurance Privacy and Accountability Act (HIPAA). For further information about our policies and standards please contact Stacy Grazak DPT at 713-668-6690.

Notice of Privacy Practices (PDF)

Notice of Privacy Practices (Webpage)