(888) 684-6064 / 8:30 AM - 5:30 PM Eastern

Thank you for your interest in Health Fitness Concepts RN, LLC (HFC). HFC maintains a large pool of licensed health professionals who perform work as independent contractors. If you are a Registered Nurse, Licensed Massage Therapist, Certified Exercise Instructor and are interested in becoming a part of our pool complete this form and we will be in touch with the next steps.

A. Identifying Information:

Last Name
First Name
Middle Name

B. Contact Information - HOME:

Street Address
City
State
Zip Code
Home Phone
Cell Phone / Cell Provider (ATT, Verizon – for texting purposes)
Fax (if applicable)
1st E-mail Address
2nd Email Address

C. Languages other than English (Spoken and understood fluently):

D. CURRENT Profession

E. MEDICAL or other License Information:

State License No Expiration Date Type of Medical License
New York
New Jersey
Connecticut

F. Additional Training and Certifications:

Please briefly describe any relevant training and experience (e.g.: specialties, phlebotomy) Training Date

Work Specific Information:

Please indicate the type of services below that you have had experience providing or would like the opportunity to be trained:

Type of Service
√ Yes, I have done before
I would welcome the opportunity to be trained or refreshed on these skills
 Blood Pressure
 Body Fat
 Bone Density
 CardioVision (arterial stiffness)
 Cholesterol Testing
 DermaScan (skin damage assessment)
 Flu Shots
 Glucose Testing
 Lung Function
 Preventive Health Counseling
 TB Testing
 Vision Screening

Massage Therapists:

• Yes or No
 Yes No Do you have a massage chair?
 Yes No Do you have a massage table?
 Yes No Are you willing to bring your table/chair to events?
 Yes No Do you provide draping for table clients?
 Yes No Is table covered with a sheet?
 Yes No Can you bring relaxing music?

Availability:

Check the days and times that you ARE available:

 Monday  Tuesday  Wednesday  Thursday  Friday  Weekends (rarely have work)

Hours:

 Anytime  Between 9:00 5:00 Other Times (i.e. 10 – 2)
Time Limitations (write below)

Areas:

 Westchester  Manhattan  New Jersey  Connecticut  Long Island

Misc.:

Do you drive? Are you willing to car pool? Do you know the subway system? Do you have space at home to store event supplies (flu shots..)
 Yes No  Yes No  Yes No  Yes No

Health Fitness Concepts RN, LLC is an equal opportunity employer –
Women and minorities are encouraged to apply.

It is the policy of Health Fitness Concepts RN, LLC to provide for and promote the equal opportunity of employment, compensation and other terms and conditions of employment without discrimination because of age, race, creed, color, religion, gender, ethnicity, alienage or citizenship status, familial status, genetic predisposition, national origin, disability, marital status, carrier status, sexual orientation, or record of offenses.

Health Fitness Concepts RN, LLC
Certified Woman Owned Business
45 Knollwood Rd. Suite 200, Elmsford, NY 10523
Phone: 914.684.6064
Fax: 914.684.6071
Toll Free: 888.684.6064
Email:info@TryHFC.com