Capital Health Careers Application for Enrollment

Last Revision: January 5, 2011

CAPITAL HEALTH CAREERS APPLICATION FOR ENROLLMENT

In order to be considered for the CHC scholarship, this form must be completed in its entirety.

Date:______SSN______

Name:______

First Middle Last Maiden

Address:______Apt.:______

City, State:______ZIP: ______County/Ward: ______

Day Phone:______Cell Phone:______

All applicants are required to provide an email address and phone number. If you do not have an email address, you will be required to create one upon acceptance into a CHC program.

Email:______

Preferred method of contact? ______Cell Phone Day Phone Email

Gender: M F DOB ______Age ______

(MM/DD/YYYY)

If you are a male between the age of 18-26, are you registered with the selective service? Y N

Are you of Hispanic/ Latino or Spanish Origin? Y N

Race (Check one or more):

American Indian/Alaska Native

Black/African American

Asian

Hawaiian Native/Other Pacific Islander

White

Other

What is the highest grade level you have completed?

8th grade and under

9th – 12th grade (some high school but did not graduate)

High school graduate or GED

1-4 years of college, or full time technical or vocational school

Associate’s Degree

Bachelor’s Degree

Are you a Veteran? Y N Dates of active duty: ______

Are you a US citizen? Y N

If no, are you a permanent resident? Y N

Are you proficient in English? Y N

Can you understand instruction and complete class assignments in English? Y N

Are you currently employed? Y N

- If yes, are you currently employed in the healthcare industry? Y N

- If you are currently working, please select which of the below three scenarios describes why you are

applying for a CHC scholarship?

The training is necessary for securing full-time employment.

The training will help me retain my current occupation.

The training will help me advance in my career.

If you are currently working, please discuss how this scholarship will advance your career.

(Please answer on a separate sheet of paper. Limit answer to one page or less.)

If you are not working, were you laid off from your last position or did you lose your job due to business closure? Y N

What was your salary at your current or last position? ______per hour

Answering the following questions about disabilities and criminal background is voluntary. Leaving them blank will have no effect on your application.

Disability: Y N If yes, please explain: ______

Have you ever been convicted of crime? Y N If yes, was it a felony or misdemeanor

How did you hear about Capital Health Careers?

UPO Providence Hospital Hospital Career Fair Website Flyer/Brochure Email Capital Health Careers Sponsored Event CUA/UDC/CCDC DOES PH-Carroll Manor Other

Are you a current or previous employee of Providence Hospital? Y N

If yes, what was your position and dates of employment? ______

In which Capital Health Careers Program do you want to enroll?

Why do you want to enroll into the Capital Health Careers Program?

(Please answer on a separate sheet of paper. Limit answer to one page or less.)

By signing, I agree that all of the information in this application is complete and true to the best of my knowledge. I realize that lying on this form may result in dismissal from the program.

Signature of Applicant______Date ______

The information submitted in the Application may be used by Capital Health Careers Partners only for admission processing, communication with you about the status of your application, and grant reporting.

Official Use: Attach documentation of eligibility (unemployed worker, displaced workerand incumbent worker)
Intake notes: