MEMBER APPLICATION

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. Please complete this form if you are interested in career counseling and/or tuition assistance.

The information submitted on this form will help the Training Fund check your eligibility, enroll you in available programs, and help you leverage any other resources and services.

If you are interested in reimbursement for professional development activities or any specialty certification (including nurse specialty certification), please complete the applicable form on our website.

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.

Date

First Name

Middle Initial

Last Name

Apprenticeship

Yes

Academic Support Materials

Yes

English Language Learning Support

Yes

Career Planning, Coaching and/or College Navigation

Yes

Continuing Education Requirements for Certifications (CEU’s)

Yes

Prerequisites/College Readiness

Yes

Professional Development

Yes

Tutoring

Yes

Tuition Assistance

Yes

Workshops

Yes

What type of Professional Development benefit would you like to use?

INFORMATION ON YOUR GOALS

What is your next career goal?

What is your long-term career goal, if different from your next goal?

Are there ways the Training Fund can help you develop within your current position? If so, how can we help you?

Do you know what college program you want to pursue? If so, what is it? If not, just say say 'No'.

If you are planning to start going to school, what term and year are you trying to start?

How did you hear about the Training Fund?

Other referral source

CONTACT INFORMATION

Primary Address

HomeWorkOther

Home Street

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 SEIU Healthcare 1199 NW Multi-Employer Training and Education Fund. You consent to receive information about career development opportunities, workshops/trainiings, 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 (Please be sure you DO NOT share this email with another hospital worker such as a family/friend/co-worker/spouse/child - each person needs to have their own email. You can use your work email if you don't have a personal email.)

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

Date of Birth

Gender (gender characteristics or identity)

Other gender (characteristics or identity)

Ethnicity (primary cultural background)

Race (race with which you primarily identify)

Country where you were born

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

Highest level of education to date (Your selection here does not limit access to benefits)

What is the primary language spoken in your home?

Fluent in languages other than English?

Can you speak, read, and write in English?

Other training/certifications? Special Skills?

Do you have challenges understanding math or written instructions?

Do you have any learning difficulties the Training Fund should be aware of?

Describe any learning challenges

BENEFIT & SUPPORT RELATED QUESTIONS

Do you know of any Educational Resources the Training Fund can partner with or assist you with to support your training or to bring additional resources to the benefit of other Training Fund Member Beneficiaries?

Do you have an active driver's license?

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

Are you a Veteran or Active Military?

Are you the spouse of a Veteran?

Do you have internet access?

Have you been homeless in the last 12 months?

Have you been homeless in the last 24 months?

Current after-tax household income per year ( just numbers, example: 55000.45, 24000, etc.)

What is your estimated total household income over the previous 6 months? ( just numbers, example: 55000.45, 24000, etc.)

Are you laid off or receiving unemployment?

What is your current household type?

What is your current living situation?

Work release completion date

How many total household members

Are you the parent, guardian, or primary caregiver of children under the age of 18?

Do you have any children or adult dependents?

Number of adult dependents

Number of children

Ages of children (ex. 3-16, or 4,7,10)

Do you use child care?

SNAP/food stamps

Yes

SSI/SSDI

Yes

TANF

Yes

Unemployment

Yes

I don't receive any of the services above, but an immediate family member (mother/ father/ sibling) does

Yes

I don't receive any of these services, but I or an immediate family member did less than 12 months ago

Yes

Other support services received

CURRENT EMPLOYER INFORMATION

Current Employer

Other Current Employer

Worksite Location/Campus

Kaiser Permanente Locations

UW Medicine, Northwest Hospital and Medical Center Locations

Swedish Medical Center Locations

UW Medicine, Valley Medical Center Locations

Job Title

Current FTE (Check with your employer if you are unsure of your FTE. For those not working with a hospital employer divide your hours worked in a week by '40' (32/40 = .8 FTE))

Union and Bargaining Unit

Approximate Date of Hire

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

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

Have you ever been employed at any of the other Training Fund contributing employers (listed above)?

What other Training Fund contributing employers have you been employed at? (select the most recent)

How many years were you employed at another contributing employer? (indicate years)

PRIOR EDUCATION HISTORY/BACKGROUND - DETAILED

What is your current education status?

School Name (Currently attending or most recent)

Additional School Name (Currently attending or most recent)

Academic Program

Degrees Obtained? Certificates Obtained?

Do you have access to your transcripts?

Did you complete your program?

If applicable, list any reason(s) for not completing any programs

What else is important that the Training Fund should know about your educational background?

Are there barriers you have overcome in your educational steps to date?

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.)

Name of previous employer

Position at previous employer

How long were you employed (in years)? If less than one year, enter zero

Approximate Starting hourly Wage ( just numbers, example: 15.45, 10.23, etc.)

Approximate Ending hourly Wage ( just numbers, example: 15.45, 10.23, etc.)

PRIVACY POLICY

https://healthcareerfund.org/wp-content/uploads/2018/08/Final-confidentiality-statement.pdf
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, or 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 the purposes of administering the Training Fund's benefits.

I agree

DATA SHARING WITH LABOR MANAGEMENT PARTNERS

The SEIU Healthcare 199NW Training Fund provides specific details about active members' usage of Training Fund pgrams 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.

Opt-out of sharing my Training Fund utilization details with employer partners:

Opt-out of sharing my Training Fund utilization details 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 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 certify that the information provided is true to best of my knowledge

True

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

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

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

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.