UFCW Member Application for SEIU 1199NW Career Counseling

Welcome to the SEIU Healthcare 1199NW Multi-Employer Training and Education Fund!

If you are a UFCW 3000 represented worker pursuing the MA-P at Renton Tech, or the MLT at Shoreline Community College or Clover Park Technical College, then this is the right application for you!

Completing this free, online application will connect you to important support and guidance on your pathway MA-P and/or MLT.

Hospital Employee Education and Training projects (HEET projects) like this are designed with healthcare workers like you in mind to create innovative opportunities for advancement through community college education.

Our goal is to support you in successfully accessing, persevering, and fulfilling your educational and professional goals. The answers you provide on this application enable us to better understand you and your specific pathway so that we can best assist you individually.

HEET partners on this project include Kaiser Permanente, MultiCare, UW Valley Medical Center and UFCW 3000, SEIU Healthcare 1199NW, and SEIU Healthcare 1199NW Multi-Employer Training Fund—all working together towards a stronger and more diverse healthcare workforce!

After you complete this application, a Training Fund specialist will reach out to you to offer more details and relevant information. We look forward to connecting and supporting you on your professional pathway!

If you need help completing this form, please contact our main office at (425) 255-0315 | members@healthcareerfund.org | www.healthcareerfund.org.

Date

First Name

Middle Initial

Last Name

INFORMATION ON YOUR GOALS

What is your next career goal?

What is your long-term career goal, if different from your next goal?

Do you know what program you want to pursue?

If you are planning to start going to school, when are you trying to start?

CONTACT INFORMATION

Primary Address

HomeWorkOther

Home Street

Home City

Home State

Home Postal Code

Home County

Preferred Phone

Mobile Phone

Home Phone

Work Phone

Can you receive texts to your preferred phone?

Preferred Email

Email (Please be sure you DO NOT share this email with another hospital worker such as a family/friend/co-worker/spouse/child - each person needs to have their own email. You can use your work email if you don't have a personal email.)

BACKGROUND INFORMATION (the Training Fund’s grant funders use background information to determine our eligibility for grants and other support)

Date of Birth

Gender (gender characteristics or identity)

Other gender (characteristics or identity)

Ethnicity (primary cultural background)

Race (race with which you primarily identify)

Country where you were born

Do you have any children or adult dependents?

Number of children

Ages of children (ex. 3-16, or 4,7,10)

Number of adult dependents

Are you the spouse of a Veteran?

Are you a Veteran or Active Military?

BACKGROUND INFORMATION, CONTINUED (the Training Fund’s grant funders use background information to determine our eligibility for grants and other support.)

Highest level of education to date (Your selection here does not limit access to benefits)

What is the primary language spoken in your home?

Fluent in languages other than English?

Can you speak, read, and write in English?

Other training/certifications? Special Skills?

Do you have challenges understanding math or written instructions?

Do you have any learning difficulties the Training Fund should be aware of?

Describe any learning challenges

CURRENT EMPLOYER INFORMATION

Current Employer

Worksite Location/Campus

Job Title

Current FTE (Check with your employer if you are unsure of your FTE. For those not working with a hospital employer divide your hours worked in a week by '40' (32/40 = .8 FTE))

FTE between 0 and 1.0

Union and Bargaining Unit

Approximate Date of Hire

PRIOR EDUCATION HISTORY/BACKGROUND - DETAILED

What is your current education status?

School Name (Currently attending or most recent)

Additional School Name (Currently attending or most recent)

Academic Program

Degrees Obtained? Certificates Obtained?

Do you have access to your transcripts?

Did you complete your program?

If applicable, list any reason(s) for not completing any programs

What else is important that the Training Fund should know about your educational background?

Are there barriers you have overcome in your educational steps to date?

PRIVACY POLICY

• https://healthcareerfund.org/wp-content/uploads/2018/08/Final-confidentiality-statement.pdf

• Please Note that in completing the attached "Application," you are also agreeing to the following statement:

I have had the opportunity to read and review the SEIU Healthcare 1199NW Training Fund Privacy Policy. By filling out and submitting this Application/Intake Form, I agree to this Privacy Policy and authorize the Training Fund to contact, or my behalf, current or previous employers or educational institutions, or other relevant entities, to obtain information that may be necessary for the administration of the Training Fund's benefits. I further understand this authorization is on-going for the purposes of administering the Training Fund's benefits.

I agree

DATA SHARING WITH LABOR MANAGEMENT PARTNERS

The SEIU Healthcare 1199NW Training Fund provides specific details about active members' usage of Training Fund programs and services to both employer and labor partners. Sharing this information allows labor/management partners to do more targeted workforce planning, and also support individuals in their career and programmatic path. Data that we share does not include Date of Birth and Social Security Number.

Do you agree to allow the Training Fund to share your information with employer partners:

Do you agree to allow the Training Fund to share your information with SEIU Healthcare 1199NW:

TEXT MESSAGING POLICY

Your education and career advancement and training opportunities are important to us. In order to provide you with the up-to-date-service, we occasionally send text messages to our participants about their education and training benefits and services. Standard text messaging rates apply.

By completing this form you authorize text messaging from Fund unless you decline text messaging. To decline Text Messages, email your Training Fund HEET Project Navigator or members@healthcareerfund.org stating that you do not want to receive text messages.

You can decline text messages at any time. Under some circumstances this may delay your receiving information on your program(s). Please talk with your Training Fund HEET Navigator (if you don’t have one, one will be assigned on submission of this form) if you have questions on text messaging.

PHOTO/VIDEO USE POLICY – TRAINING FUND EVENTS

The ability to communicate about Training Fund services to our members and to use information gathered in classes and sessions for further training is important to the Training Fund.

Unless you decline photo/video by the Fund, by completing this form you authorize and agree that the SEIU Healthcare 1199NW Multi-Employer Training & Education Fund and SEIU Healthcare 1199NW may use photographic images or video footage of you, or in which you are included, taken during Training Fund related classes, sessions, or events, for public relations, program marketing, electronic media, or educational purposes.

To opt out from photo/video use, please send a separate email your Training Fund HEET Project Navigator or members@healthcareerfund.org stating that you do not want your images/video to be used for Training Fund purposes.

You may opt out of photo/video use at any time. Please talk with your Training Fund HEET Project Navigator (if you don’t have one, one will be assigned on submission of this form) if you have questions on photo/video use.

NON-DISCRIMINATION POLICY STATEMENT

The Training Fund is dedicated to equal opportunity education and training. It does not discriminate on the basis of race, creed, color, ethnicity, national origin, religion, sex, sexual orientation, gender expression, age, physical or mental ability, veteran status, military obligations, background, or marital status.

VERIFICATIONS

You MUST sign at the bottom of this page and click the 'Submit Signed Response' button to complete your application/intake form. You will then receive an email with a link to confirm your Signature…this form is not submitted until it is signed and your signature is confirmed.

I certify that the information provided is true to best of my knowledge. I am aware that the information I have provided is subject to review and verification, and I may have to provide documentation to support the information provided.

I certify that the information provided is true to best of my knowledge

True

I authorize release of this information for verification purposes and for determining eligibility for services and Training Fund and non-training Fund benefits. I agree to the Training Fund Privacy Policy. I understand that receiving services is subject to availability of funding and that training and/or services are not guaranteed.

I authorize release of this information

True

I desire to be screened for benefit eligibility and enrollments. I authorize the release of my information and job placement data to Training Fund staff and affiliates for program monitoring, research, verification, additional data collection, and evaluation purposes.

I agree

True

By signing with my mouse/cursor or typing my full name below as my signature, and submitting this form, I verify and confirm the statements above.