EDUCATIONAL PATHWAY ENROLLMENT

Welcome to the Health Care Apprenticeship Consortium's Program Application!

Your information helps the Health Care Apprenticeship Consortium (HCAC) support training opportunities for you and your community.

We’re excited about helping you achieve your education and professional development goals!

We do not divulge the individual responses to anyone outside the consortium unless required by our programs. We do not sell your information. The consortium is an equal opportunity training entity.

Date

REFERRAL SOURCE

How did you hear about this program?

Other referral source

Which apprenticeship or program is this application for?

CONTACT INFORMATION

Primary Address

HomeWorkOther

First Name

Middle Initial

Last Name

Home Street Address (including unit #)

Home City

Home State

Home Postal Code

Home County

Preferred Phone

Mobile Phone

Home Phone

Work Phone

Permission to Text (Optional) By agreeing here, you're signing up to receive SMS text communication from the Healthcare Consortium SEIU Healthcare 1199 NW Multi-Employer Training and Education Fund. You consent to receive information about career development opportunities, workshops/trainings, and resources at the number proivded. Message and data rates may apply. Message frequency varies. For help reply HELP, to opt out reply STOP. View Terms of Service HERE and Privacy Policy HERE.

Preferred Email

Email

Additional Email on File (please edit if you'd like to provide an addional email)

Do you have internet access?

What type of device do you use to access the Internet?

Do you need to borrow a laptop? (If you answer yes, please look for the application in your email).

Reliable Internet connection is required to participate in the program. Do you need to borrow an Internet signal booster to supplement your home Internet connection speed? (If you answer yes, please look for the application in your email).

DEMOGRAPHIC INFORMATION (HCAC grant funders use background information to determine our eligibility for grants and other support)

Date of Birth

01/10/2022

Gender (gender characteristics or identity)

The information from this application form feeds into the Washington State Apprenticeship Agreement, which only has two gender options. For this form, please select the gender that you most identify with:

Race (race with which you primarily identify)

Ethnicity (primary cultural background)

Country where you were born

Can you speak, read, and write in English?

What is your highest level of education?

Are you a Veteran or Active Military?

Are you the spouse of a Veteran?

Do you have a drivers license?

What is your primary means of transportation?

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

INCOME & HOUSEHOLD INFORMATION - This data is used to determine eligibility for extra support services and for our funders.

Have you been homeless in the last 24 months?

Have you been homeless in the last 12 months?

Approximate gross household income last year (use numbers only)

How many total household members do you have?

Approximate current hourly wage (just numbers, example: 15.45, 10.23, etc.)

EMERGENCY CONTACT INFORMATION

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone Number

Relationship to you

CURRENT EDUCATIONAL CHALLENGES – Your feedback helps HCAC support you and identify whether you qualify for outside support and grants.

Do you have any learning difficulties HCAC should be aware of?

Describe any learning challenges

Do you have a disability requiring an accommodation?

COHORT SCHEDULE

Are you able to commit to 3 days per week of class on Zoom and 1 in-person day from 9am-3pm for Weeks 1-4; Clinical Prep/Make-up/and Clinical Orientation for Week 5; and 40 hours of scheduled Clinicals for Week 6 (could be 7am-7pm or 7am-3pm)?

If you cannot make this commitment now, would you like to be contacted about future NA-C training classes??

What other commitments will you have while participating in the program? (select all that apply)

Is your current employer willing to rearrange your work schedule and hours to accommodate your participation?

Clinical Sites (in-person learning) require complete immunization/vaccine history and a current (with 12 months) TB test. Please acknowledge that you will need to provide and/or get blood work to confirm immunity.

I acknowledge that I will need to submit current vaccine records.

Some Clinical locations require COVID-19 vaccinations and do not accept exemptions. Completing 40 hours of clinical is required for the completion of the program. We will try our best to find alternative clinical placement if you have a COVID waiver but please acknowledge this could delay your clinical placement .

I acknowledge the above informationI have been vaccinated for COVID-19 and can provide records

There is a background check process in order to go to clinical. Please acknowledge that you understand this..

I understand.

Lead Source

Record Type

Wage

Apprentice record Id

Stage

CURRENT EMPLOYER INFORMATION

Employer for your Apprenticeship

Other Employer

Worksite Location/Campus

Job Title

Union and Bargaining Unit

Date of Hire (Note: If you are not currently employed with your apprenticeship employer, please list future date.)

Kaiser Permanente Locations

UW Medicine, Northwest Hospital and Medical Center Locations

Swedish Medical Center Locations

UW Medicine, Valley Medical Center Locations

CURRENT LIFE CHALLENGES – Your feedback helps HCAC support you and identify whether you qualify for outside support and grants.

Are any of the following issues affecting you or concern you now?

Are there any other challenges that will impact your continuing education?

Is there any additional information you'd like HCAC to know?

PRIVACY POLICY

• Privacy Policy

• 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, on 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 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. Your information may be shared with grant issuers.

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 members 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 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 our staff (if you don’t have one, one will be assigned on submittal 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 Regional Education 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 Navigator (if you don’t have one, one will be assigned on submittal 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.

ADDITIONAL INFORMATION

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

RELEASE OF INFORMATION

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

DATA COLLECTION

I understand for educational and grant purposes, my employment status may be tracked after completion of my educational support. In order to verify the information or conduct further program evaluation, I understand the Training Fund may need to collect additional information from records at government agencies. This information may include but not be limited to Washington State Employment Security Department, Social Security Administration, Washington State Basic Food Employment and Training, or TANF (Temporary Assistance to Needy Families) records.

I understand the Training Fund may need to collect additional information

True

SCREENING

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

EDUCATIONAL PATHWAY ENROLLMENT - ARIVVA

VERIFICATIONS