MEMBER APPLICATION

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

We’re excited about helping you achieve your education and professional development goals. The information submitted on this form will help the Training Fund provide you with benefits assistance, check eligibility, enroll you in available programs, and help the Fund leverage other services for you and your fellow members’ support.

Your Regional Education Navigator can help you with this form. If you have questions, please call us at 425-255-0315 or email us at members@healthcareerfund.org.







This application/intake is being completed for: [check all that apply]












INFORMATION ON YOUR GOALS





CONTACT INFORMATION















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










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









BENEFIT & SUPPORT RELATED QUESTIONS





INCOME & HOUSEHOLD INFORMATION (Your information is to determine eligibility for scholarships, extra support services and grant funding.)










Are you currently receiving any of the following services: (Please check all that apply)







CURRENT EMPLOYER INFORMATION















PRIOR EDUCATION HISTORY/BACKGROUND - DETAILED









YOUR LAST JOB/EMPLOYMENT HISTORY (Information on both your current job and your last job helps determine eligibility for scholarships, extra support services and grant funding.)





OTHER BACKGROUND


EMERGENCY CONTACT INFORMATION







CURRENT LIFE/EDUCATIONAL CHALLENGES – (how can we best support you? Will other outside support we assist with be helpful? Your feedback helps the Training Fund identify other qualifications for outside support and grants)


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























PRIVACY POLICY

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 your Regional Education 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 Navigator (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.

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 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 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 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.


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.

SEIU 1199NW Training Fund | 15 S. Grady Way, Suite 321 | Renton, WA 98057 | (425) 255-0315 | www.healthcareerfund.org | members@healthcareerfund.org