Employee Work-wear/Training Agreement Community:
Employee Name (Printed):
I understand that the work-wear I will receive, including any additional accessories such as gait belts etc., belongs to Ageia Health Services and I agree to return these to my supervisor upon my separation from Ageia Health Services. I also understand that if I fail to return my uniforms and / or gait belt on my last day of work,, the uniform cost ($25.00 each piece) and / or the gait belt cost ($20) will be deducted from my final paycheck. I also understand that the value of any training I am provided will be subtracted from my final paycheck according to the amounts listed below if I am employed for less than 12 months. Uniform Shirts
($25.00 value)
O Yes
O No
Qty:
Size:
Kitchen Shirts
($25.00 value)
O Yes
O No
Qty:
Size:
Gait Belt
($20.00 value)
O Yes
O No
Qty:
Size:
First Aid Training/CPR
($100.00 value)
O Yes O No
Food Handlers Card
($15.00 value)
O Yes O No
Nurse delegation (WA.)
($100.00 value)
O Yes O No
Fundamentals (WA.)
($150.00 value)
O Yes O No
Dementia (WA.)
($100.00 value)
O Yes O No
Mental Health (WA.)
($100.00 value)
O Yes O No
Developmental Disability (WA.)
($100.00 value)
O Yes O No
aQuire CAREPRO (for WA. HCA Cert.) ($100.00 value)
O Yes O No
WA. CHCA State Application Fee
($85.00 value)
O Yes O No
($127.00 value)
O Yes O No
(NA if participating in aQuire CAREPRO)
WA. Prometrics Written Testing Fee
WA. Prometrics Oral Testing Fee ($127.00 value) O (Re-testing fees due to non-passing score are the responsibility of the employee)
Yes O No
Employee Signature: Date:
Ageia Health Services
Updated: 5-26-2016
