catch application

8/13/2019 CATCH application

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C TCH Grantpplication PacketThe CATCH Program provides expense-paid foundation training for

select health care professions at Edmonds and Everett Community

Colleges, preparing students for success in a wide variety of

well-paying, in-demand health professions

Student Checklist Complete Application

Drop-off, mail, fax or email packet to CATCH office

Physical Address: 6600 196thST SW, Lynnwood, WA (Next to Ice Arena)

Mailing Address: Edmonds CC, CATCH Grant, 20000 68thAve W, Lynnwood, WA 98036

Fax: 425-640-1363

Email: [email protected]

Phone: 425-640-1361

After eligibility review CATCH staff will contact you to schedule an Assessment

Attend 4 hour Information/Assessment session at CATCH office at Edmonds CC.

Staff Use only:

WorkFirst TANF BFET Other income eligibility

___ TANF Eligible ___ Food Stamp approval ___ WIA

___ IRP approval ___ BFET/DSHS approval ___Opportunity Grant or TRIO

___ E-JAS Referral ___ Working Connections ___ Income (175% Federal Guide)

___ Permanent resident, eligible for financial aid _____ High School Diploma or GED

The Health Profession Opportunity Grant (HPOG)/CATCH program is a demonstration project funded by the Administration for

Children and Families (ACF) in the U.S. Department of Health and Human Services (HHS).

The primary goals of this project are to:

1. Provide education and training to low-income individuals for occupations in healthcare that pay well

2. Learn what kinds of education and training programs work.

In order to learn what works, we are conducting a study requiring every person eligible for CATCH/HPOG to be selected through alottery system. Those not selected through the lottery will not be able to participate in CATCH, but will be able to enroll in any

other college or community services or programs for which they are eligible.

This document was supported by Grant 90FX0025-02-00 from the Administration for Children and Families, U.S. Department of Health & Human

Services (HHS). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HHS.


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Name:_________________________________________

Application Date:__________________

Preferred CATCH Start Date:

___ September 3, 2013, Edmonds Community College

___ November 12, 2013, Edmonds Community College___ January 6, 2014, Everett Community College

___ February 10, 2014, Edmonds Community College

Agency Referring Applicant (if any): _________________________________________

CATCH Grant Application

2013-2014

APPLICANT INFORMATION

Name: (First, Middle, Last)

Current Address:

City: State: ZIP Code:

Aliases/Maiden Name:

Soc Security Number: Date of Birth: Age:

Cell phone: Alternative phone: Email:

Emergency Contact: Relationship: Phone:

Veteran? _____ Yes _____ No Tribal Affiliation? _____ Yes _____ No Race/Ethnicity:

BASIC ELIGIBILITY

US Citizen? ____ Yes ____ No Place of Birth:

If not, Permanent Resident Card #: Exp Date:

Languages Spoken:

Receiving TANF cash benefits? ___Yes ___ No If so, how long:

Do you receive Basic Food(Food Stamps) ___ Yes ___ No

TANF Grant/month? $ CSO Office:


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BACKGROUND CHECKS

As required to apply for Nursing Assistant Certification in Washington State and a condition of employment inhealthcare, CATCH conducts an in-depth criminal background check on each applicant.

For additional information about state requirements visit : http://www.doh.wa.gov

Have you ever been convicted, entered a pleas of guilty, no contest, or a similar plea, or had prosecution or a sentence deferred orsuspended as an adult or juvenile in any state/jurisdiction? _____ Yes _____ No If yes, please explain:

Are you now subject to criminal prosecution or pending charges of a crime in any state or jur isdiction? _____ Yes _____ No

If yes, please explain:

Other than any matter above, is there any fact or circumstance involving you and your background that would call into questionyour being entrusted with the care, guidance or supervision of vulnerable adults, young people or developmentally disabledpersons? _____ Yes _____ No If yes, please explain:

PERSONAL & FAMILY NEEDS AND SUPPORT SYSTEMS

Marital Status: ____ Single ____ Married ____ Separated ____ Divorced Number of family in household: _______

Number of children under age 18 in your family: Ages of your children:

If you have children of child care age, what is your plan for them while you are in CATCH? Do you already have child care in place,or will you need assistance in securing child care? Please describe

Do you have active health problems that could interfere with

your schooling or healthcare employment?_____ Yes _____ No If yes, please explain:

Are you physically able to:

Stay on your feet for 8 hours? _____ Yes _____ No

Lift 50 pounds? _____ Yes _____ No

Drag 100 pounds? _____ Yes _____ No

Do you smoke? ___Yes ___ No

Smoking is not permitted inside healthcare facilities and is nolonger allowed on the grounds of most. Healthcare facilities mustprovide an overall healthy environment to patients and visitorsand secondhand smoke has been proven hazardous to peoples

health. For those needing to quit, help exists so please inquirewith staff.

Are you pregnant? ___Yes ___ No

If so, Due Date: ______________

**Being pregnant does not disqualify you from this program.

Do you have any counseling appointments that would interfere with your schooling?

Do you have other personal issues that could interfere with your schooling in the next few months? (domestic violence, substanceabuse, legal or court dates?)

How do you plan to travel to class: _____ Car _____ Bus _____ Other


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CATCH APPLICATION

EDUCATIONAL BACKGROUND

High School Diploma: _____ Yes _____ No

If no, highest grade completed: __________Date earned:

Name/Location of High School:

Did you earn a GED? _____ Yes _____ No Date earned:Name/Location of granting institution:

Have you attended a Washington State College _____ Yes _____ No

Date attended: ________ Student ID #: ______________________

Do you have any outstanding student loan debts?_____ Yes _____ No

If so, how much do you owe and name of school:

Please list all training, classes or certificates since high school or GED diploma

Name of School:

Type of Training:Dates:

Completed? _____ Yes _____ No

Name of School:

Type of Training:

Dates:


Name of School:

Type of Training:Dates:


Is English your first language? _____ Yes _____ No

If not, please list your first language:

Have you taken ESL classes (English as a Second Language)?_____ Yes _____ No

If yes, Highest ESL class/level completed: ____________

EMPLOYMENT HISTORY

Do you currently work in a healthcare job?_____ Yes _____ No

Job title: Name/Location of Employer:

Have you ever worked in a healthcare job?_____ Yes _____ No

Job title: Name/Location of Employer:

Please list your most recent experience. Include work experience, volunteer or community service positions

Job Title: Dates: Name/Location of Employer:

Supervisor: Reason for leaving:

Job Title: Dates: Name/Location of Employer:

Supervisor Reason for leaving:

Job Title: Dates:

Supervisor Reason for leaving:


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This document was supported by Grant 90FX0025-02-00 from the Administration for Children and Families, U.S. Department of Health &

Human Services (HHS). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HHS.

CATCH APPLICATION

PERSONAL REFERENCES

Please provide the names of two local individuals (supervisor, case manager, pastor, landlord, etc. ) besides familyor relatives, whom we can contact for a personal character reference.

Name: Phone: Occupation:

Street address:City:State:

Email: Years known:___________How do you know this person:

Name: Phone: Occupation:

Street address:City:State:

Email: Years known:___________How do you know this person:

CAREER GOALS AND EMPLOYMENT READINESS

What interests you about a career in healthcare? Please state your job and career goals.

How will the CATCH Program help you achieve these goals?

Please list any obstacles coming up in the next nine months that might prevent you from completing this training and/or acceptingimmediate employment.

AUTHORIZATION

The Health Profession Opportunity Grant (HPOG)/CATCH program is a demonstration project funded by the Administration forChildren and Families (ACF) in the U.S. Department of Health and Human Services (HHS).

The primary goals of this project are to:1. Provide education and training to low-income individuals for occupations in healthcare that pay well2. Learn what kinds of education and training programs work.

In order to learn what works, we are conducting a study requiring every person eligible for HPOG to be selected through a lotterysystem. Those not selected through the lottery will not be able to participate in HPOG, but will be able to enroll in any otherservices or programs for which they are eligible.

I have read the information contained in this application. I certify the information given is true and correct.By signing below, I authorize the Edmonds Community College CATCH Grant program to:

1. Conduct background checks and to obtain any and all information needed to process my application.2. I give Edmonds CATCH grant program permission to share necessary information with college staff at

Edmonds Community College and Everett Community College, community partners and any governmentalentity and law enforcement agency.

Signature_____________________________________________________________ Date ______________


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