Youth Apprenticeship Program

SHEBOYGAN AREA

YOUTH APPRENTICESHIP PROGRAM

2014 HEALTH APPLICATION

Have you discussed the commitment of an apprenticeship with your parents/guardians? Do you understand that applying for an apprenticeship does not guarantee an interview? If hired, will you be able to work before, during or after school? How about weekends, holidays and over the summer? If you’re interested in a Health- Nursing Assistant apprenticeship please be advised that successful completion of the state certification in Nursing Assistant is required (approx. cost $115)

Every student interested in participating in Youth Apprenticeship will be required to complete the application process, which includes:

Background Information and Time Commitment Forms
Parent or Guardian Information
Parent/Guardian Certification and Release Form
Employment History
Applicant Program Interest Essay

All students must also complete the required Accuplacer Testing PRIOR to

FEBRUARY 28, 2014. More information about the Accuplacer Testing can be found on the yellow sheets within the provided information packet.

YOU MUST SUBMIT THE FOLLOWINGDOCUMENTS WITH THIS APPLICATION

1. A copy of your high school transcript.

2. A copy of your high school attendance record for the current year.

3. Two recommendations are required. (One math or science teacher, one counselor/teacher/advisor/coach) Please see forms for submission requirements.

4. For all CNA applicants- a two-hour verified job shadow is required for the interview process.

Fees- for Nursing Assistant ONLY- will be discussed further at a regional meeting

$30 LTC Application Fee
$16 Background Check Fee
Check with nurse on TB Testing, free if parent fills out a parental consent, done at LTC
$115 (approx.) for State of Wisconsin Nursing Assistant Certification Test

2014 HEALTH APPLICATION FORM

Sheboygan Area Youth Apprenticeship

HEALTH LEVEL-ONE

MISSION STATEMENT

The Wisconsin Health Youth Apprenticeship Program provides career preparation for high school students with an interest in nursing. Participation in this program allows the student an opportunity to establish a strong foundation in health care. Program requirements include work-based and educational components related to the nursing field.

STUDENT NAME: ______DATE: ______

HIGH SCHOOL: ______

HEALTH SCIENCE—ONE YEAR PROGRAM

Please indicate your choice of program(number 1 being highest preference-3 being lowest)

CERTIFIED NURSING ASSISTANT-SENIORS ONLY
DIETARY-JUNIORS OR SENIORS
MEDICAL ASSISTANT- JUNIORS & SENIORS
MEDICAL OFFICE- JUNIORS & SENIORS

RETURN COMPLETED APPLICATION AND DOCUMENTS

TO YOUR HIGH SCHOOL YOUTH APPRENTICESHIP LIAISON

BY February 21, 2014

LTC YOUTH APPRENTICESHIPCOORDINATOR WILL PICK UP AT HIGH SCHOOL

DEADLINE: February 24, 2014

No individual shall be excluded from participation in, denied the benefits of, subjected to discrimination under, or denied employment in the administration of or in connection with any Wisconsin Health Youth Apprenticeship Program on the basis of race, color, religion, sex, national origin, age, handicap, political affiliation or belief, or sexual orientation.

Sheboygan Area Youth Apprenticeship Application

WISCONSIN HEALTH ONE YEAR PROGRAM

I. BACKGROUND INFORMATION

Student Name ______

Address______

City______Zip______Date of Birth ______

Phone ______Cell Phone ______

High School______E-mail ______

Grade level for 2014-15 (check one) ______Junior ______Senior

Please list your high school activities, community service activities, honors received, and offices held.

Please list any courses or training you have completed that will enhance your qualifications for the Wisconsin Health Youth Apprenticeship Program.

Please comment on your high school attendance record for the current year if any clarification is needed.

YOUTH APPRENTICESHIP TIME COMMITMENT

(June 2014-May 2015)

I understand that a Youth Apprenticeship requires a time commitment beyond that of a typical high school student. I will be asked to provide my work site with specific hours and days that I will be available to work. I understand that timely communication with my work site mentor regarding changes in my personal schedule is extremely important.

Below is a list of the other extracurricular activities (sports, musicals, band, vacations etc. in which I currently plan to participate, as well as a summarized timeline for each activity. I am providing as much information as I have available and being as specific as I possibly can at this time.

ACTIVITY PLANNED / GENERAL TIMEFRAME (MONTHS) / EXPECTED TIME OF DAY/HOURS
Example: Football / August through November / Practice M-Th from 3-7pm, game every Friday

A Youth Apprentice must complete 450 total work hours during the year, which usually includes summer work scheduling. This means that a typical Youth Apprentice dedicates an average of 10-12 hours per week to their job during the school year, and often more time during the summer.

As a Youth Apprentice, I agree to:

Maintain the academic and attendance requirements enforced by the Youth Apprenticeship Partnership, my school and my work site.
Observe company and school rules and other requirements identified by the employer.
Participate in progress reviews scheduled with mentors, school personnel and parents/guardians.

Student Signature ______Date ______

Parent Signature ______Date ______

II. PARENT OR GUARDIAN INFORMATION

Father's Name ______Daytime Phone ______

Mother's Name ______Daytime Phone ______

Guardian's Name ______Daytime Phone______

Parent E-mail address ______

If parent address is different than student address, please list the parent address below.

Address ______City ______Zip ______

Phone ______

PARENT/GUARDIAN CERTIFICATION AND RELEASE

Parent/guardian initials before each statement, student and parent/guardian sign below.

____I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if my student is selected for the Youth Apprenticeship Program, falsified statements may be grounds for removal.

____I certify that my student has a clean driving record and no felony convictions.

____I authorize investigation of all statements contained herein and the references listed in this application and all information concerning previous employers, and release all parties from liability for any damage that may result from furnishing those to you.

____I understand that LTC tuition fees/textbook costs required for related courses will be paid for through the Youth Apprenticeship grant if my student earns a grade of C or higher, and if a grade below C level is received, all costs will be the responsibility of my family.

____I understand that a parent/guardian must attend, along with my student, any orientation session that may be required for the Youth Apprenticeship Program for which my child wishes to apply.

____I authorize the release of transcripts of grades and attendance records.

____I understand that I am solely responsible for the transportation of the undersigned student to and/or from the classroom or the work site and for all loss involved in said transportation.

____I certify that the student has a valid driver’s license and adequate car insurance (necessary only in those cases where the student will be driving to classroom or work site).

STUDENT SIGNATURE ______DATE ______

PARENT SIGNATURE ______DATE ______

EMPLOYMENT HISTORY- please list previous employment:

Employer's Name ______Dates of Employment ______

Address______City/ZIP ______Phone ______

Work Assignment ______Supervisor ______

Comments:

Employer's Name ______Dates of Employment ______

Address ______City/ZIP ______Phone ______

Work Assignment ______Supervisor ______

Comments:

APPLICANT PROGRAM INTEREST ESSAY

In a typewritten or word processed format, please explain why you feel you should be selected for the Youth Apprenticeship Program. Do not exceed 250 words. Please include answers to the following questions:

a) Why are you interested in the Youth Apprenticeship Program?

b) How do your career interests relate to the program area for which you are applying?

c) Why do you think you should be considered as an apprentice?

d) What is your long-term career goal?

Program Related Instructor Recommendation Form

Student Name Grade ______High School ______

This student is applying for the Wisconsin Health Youth Apprenticeship Program

The following checklist is provided for those who know the student well enough to give us an accurate assessment of him/her. We hope that it will provide a convenient method to describe the candidate in summary fashion.

No Basis for
Judgement / Below
Average / Average / Above
Average / Excellent
(top 10%)
Academic Performance/Quality of Work
Responsibility
Attitude
Effort
Honesty
Dependability
Teamwork/Cooperation
Problem Solving
Leadership
Attendance

Please make other comments that will indicate your estimation of this student's qualifications for this program.

______Printed Name of Reference Person Position/Subject Taught

______Signature Date

Return to High School Youth Apprenticeship Liaisonin a sealed envelope with your initials signed on the seal by February 21, 2014 or e-mail to .

High School Personnel-Counselor, Club Advisor, Coach,Teacher

Recommendation Form

Student Name Grade ______High School ______

Please make other comments that will indicate your estimation of this student's qualifications for this program.

______Printed Name of Reference Person Position/Subject Taught

______Signature Date

Return to High School Youth Apprenticeship Liaisonin a sealed envelope with your initials signed on the seal by February 21, 2014 or e-mail to .

Wisconsin Health Youth Apprenticeship Program

Job Shadow Verification Form

FOR NURSING ASSISTANT ONLY

As part of the application process for the Wisconsin Health Youth Apprenticeship Program, applicants must complete a two-hour job shadowing experience with a Certified Nursing Assistant (CNA). Please ask your YA Liaison or your high school counselor for assistance in this process. This verification form must be completed and returned to your school YA LiaisonPRIOR to May, 2014 or your scheduled interview date.

Applicant’s Name High School______

Job Shadow Site______

Address ______

Job Shadowing Date ______Date ______

A. To Be Completed by the CNA:

Name (printed) of CNA observed ______

Signature ______

Student Start and Finish Times______Date ______

B. To Be Completed by the Applicant:

(Attach separate paper with responses to 1-4).

1. What are some of the responsibilities of a CNA (Certified Nursing Assistant)?

(Consider what you observed and discussed with the person you shadowed).

2. Why do you feel that working as a CNA will be a valuable learning experience? How do you see the CNA as a foundation for future health services careers?

3. What concerns do you have about becoming and working as a CNA? How will you handle these?

4. Were any of your career plans changed or reinforced by this experience? Explain.

Revised 1/13/2014