Youth Apprenticeship Program

SHEBOYGAN AREA

YOUTH APPRENTICESHIP PROGRAM

2016 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? Most healthcare facilities require that ALL employees are available every other weekend to work. 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. All applications must be TYPED. The application includes the following:

Background Information and Time Commitment Forms
Parent or Guardian Information
Parent/Guardian Certification and Release Form
Employment History
Applicant Program Interest Essay
Attend Mandatory Nursing Assistant Forms & Fees Night on

Monday, April 4, 2016-5:30-6:30 p.m. at LTC Cleveland

THE LINK TO COMPLETE THE ELECTRONIC APPLICATION CAN BE FOUND AFTER FEBRUARY 9, 2016 AT:

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 verified job shadow is required for the interview process.

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

$16 Background Check Fee—check made out to: LTC
Complete TB Test
$115 (approx.) for State of Wisconsin Nursing Assistant Certification Test

2016 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

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

CERTIFIED NURSING ASSISTANT-SENIORS ONLY—
Must also complete the required Accuplacer Testing PRIOR to
MARCH15,2016. More information about the Accuplacer Testing can be found on the yellow sheets within the provided information packet
DIETARY-JUNIORS OR SENIORS
MEDICAL OFFICE- JUNIORS & SENIORS (limited opportunities)

STUDENTS

RETURN COMPLETED APPLICATION AND DOCUMENTS

TO YOUR HIGH SCHOOL YOUTH APPRENTICESHIP LIAISON

BY February 26, 2016

LTC YOUTH APPRENTICESHIPCOORDINATOR WILL PICK UP AT HIGH SCHOOL

DEADLINE: March 3, 2016

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 SchoolE-mail

Grade level for 2016-17 (check one) Junior Senior

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

Please list any courses,training or experiences 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 2016-May 2017)

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.
Understand that if I am hired by an employer, any requests I make to switch or transfer places of employment will not be honored or fulfilled by the YA program unless warranted and mutually agreed upon by all affected parties.

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

PRINT PAGE and then have Parent/guardian initial 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 understand that the student will be required to complete a background check and drug screening if offered employment.

____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 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 the student must consult the high school liaison on payment for needed textbooks, but it is the responsibility of the student to obtain necessary text book prior to the start of the LTC class

____I understand that a parent/guardian must attend, along with my student, any orientation session and grading conferences that are 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

Student comments about work responsibilities and learning experiences:

Employer's Name Dates of Employment

Address City/ZIP Phone

Work Assignment Supervisor

Student comments about work responsibilities and learning experiences:

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 High School Instructor

Recommendation Form—PRINT PAGE before completing

Return to High School Youth Apprenticeship Liaisonin a sealed envelope

Student Name Grade ____ High School ______

This student is applying for the Wisconsin Health Youth Apprenticeship Program

Please refer to the checklist below to provide an accurate assessment of the applicant in the following areas.

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 provide additional comments of the 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 26, 2016 or e-mail to

High School Personnel

Counselor, Club Advisor, Coach, Non-Program Teacher

Recommendation Form-PRINT PAGE before completing

Return to High School Youth Apprenticeship Liaisonin a sealed envelope

Student Name Grade ______High School ______

Please refer to the checklist below to provide an accurate assessment of the applicant in the following areas.

Please provide additional comments of the 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 26, 2016 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 job shadowing experience with a Certified Nursing Assistant (CNA). Please contact Jackie Holly at 920.693.1128 or or assistance in this process. This verification form must be completed and returned to Jackie Holly at LTC Cleveland, 1290 North Ave., Cleveland WI 53015 PRIOR to May, 2016 or your scheduled job interview date.

Applicant’s Name High School______

Job Shadow Site______

Address ______

Job Shadowing Date ______Date ______

A. To Be Completed by the CNA you are shadowing:

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).

(Hand-written answers on this form will not be accepted)

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 role asa 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 1/22/2016