Flint Healthcare Employment Opportunities Program Application

▼Personal Data

Date of Intake Proposed Cohort # Cycle How did you hear about us? *

First Name * Middle Name Last Name *

Please list any other names you have used:

Date of Birth Current Age Race Age at Intake

Gender Assigned Career Advisor Pronouns Other Pronoun

Address

Address Line 1 Address Line 2

City State Zip

Primary Phone * Consent to receive text messages? * Alternate Phone Email Address *

Social Security Number Drivers License Number

Emergency Contact

First Name Middle Name Last Name

Address Line 1 Address Line 2

Primary Phone Alternate Phone Email Address

▼Education and Training

What is the highest level of education you have completed? Name of School Date Completed Currently enrolled in a College, Technical, Vocational, or Business Institution?

If yes, please provide the name of the institution:

Healthcare Training Interest — Choice 1 Choice 2 Choice 3

▼Employment Status at Intake

Are you currently employed? Employer's Name Your Current Title Your Current Salary/Wage

Employer's Address Line 1 Employer's Address Line 2

Employer's City Employer's State Employer's Zip Your Starting Wage

Hours per week Supervisor Name Supervisor Title Supervisor Contact Number

May we contact your supervisor?

Employment History — Employer 1

Employer 1 Job Title Start Date End Date

Type of Business Starting Wage Final Wage Supervisor's Name

Supervisor's Title Supervisor's Contact Number Key Responsibilities

Employment History — Employer 2

Employer 2 Job Title Start Date End Date

Type of Business Starting Wage Final Wage Supervisor's Name

Supervisor's Title Supervisor's Contact Number Key Responsibilities

▼References

Please list two references below:

Reference 1: First Name Reference 1: Middle Name Reference 1: Last Name Reference 1: Years of Acquaintance

Reference 1: Type of Reference Reference 1: Company Reference 1: Phone Number

Reference 2: First Name Reference 2: Middle Name Reference 2: Last Name Reference 2: Years of Acquaintance

Reference 2: Type of Reference Reference 2: Company Reference 2: Phone Number

▼Legal History / Criminal Background Check Information

Have you ever been convicted of any felony or misdemeanor? If yes, when, where and what was the nature of the felony or misdemeanor?

Are there any charges pending? If yes, what is the nature of the charge?

I understand that in order to qualify for the Flint Healthcare Employment Opportunities (FHEO) Program, I must submit to, and successfully pass a criminal background check for prior felony abuse/assault related convictions and a drug screening.

▼Supplemental Information (18–24 Year Old Candidates)

Are you Homeless, Runaway, or Previously in Foster Care? Are you a Pregnant or Parenting Youth? Do you have a disability? Are you low income?

Have you been laid off from a job within the last 12 months? Have you ever registered for WIOA / WIA Program? If yes, name of service provider:

Have you been designated a Dislocated Worker by Michigan Works!? If yes, name of service provider: Are you an FHEO Program Graduate?

▼Confidentiality Agreement

I understand that the information provided to the FHEO Program is strictly confidential and will be utilized by the FHEO Program partners to determine if I am ready to make the commitment to participate in a structured training program. *

▼Screenings

Has applicant completed the Healthcare Career Readiness Assessment (HCRA)? HCRA Average Score Date HCRA Completed Background Check Status

Has the applicant completed CASAS Assessment? Reading Score Locating Score Math Score

Date Background Check Performed Date of Interview Interview Score Results of Drug Screen

Date of Drug Screen

▼Applicant Intake Data

FHEO Pathway Program Registration Source of Application Referring Community Partner