Healthcare Heroes Application

First & Last Name [ Example: John Smith ] :

Mailing Address [ Example: 1 Main St Elmsford, NY 10523 ] :

Email Address [ Example: info@rytescompany.com ] :

Which Facility Do You Work In? [ Example: Rytes Rehabilitation Center ]

Have you worked an excess of 175 hours between 4/15/2020 and 5/15/2020?

Yes

Please provide the name and phone number of your employer's HR Department [ Example: John Doe (555) 555-5555 ] :

Have you tested positive for COVID-19 anytime after April 15th, 2020?

Yes

Are you a direct care provider? (As opposed to a supervisor or a member of management)

Yes

I am a(n) __________.

LPN

CNA

Physician Assistant

Licensed Therapist providing direct patient care

Other

If you work as an aide, are you certified? (If you are not an aide, click next)

Yes

If you work as a nurse, are you certified? (If you are not a nurse, click next)

Yes

Time is Up!

+1-(888)-99-RYTES (79837)