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CATCH Grant

Application Packet The 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

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Drop-off, mail, fax or email packet to CATCH office Physical Address: 6600 196th ST SW, Lynnwood, WA (Next to Ice Arena) Mailing Address: Edmonds CC, CATCH Grant, 20000 68th Ave W, Lynnwood, WA 98036 Fax: 425-640-1363 Email: [email protected] Phone: 425-640-1361

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

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

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 a lottery 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.

Staff Use only: WorkFirst TANF ___ TANF Eligible ___ IRP approval ___ E-JAS Referral

BFET ___ Food Stamp approval ___ BFET/DSHS approval ___ Working Connections

___ Permanent resident, eligible for financial aid

Other income eligibility ___ WIA ___Opportunity Grant or TRIO ___ Income (175% Federal Guide) _____ High School Diploma or GED

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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CATCH Grant Application 2014-2015 Name:_________________________________________ Application Date:__________________ Preferred CATCH Start Date: ___ November 2014, Edmonds Community College ___ January 2015, Everett Community College ___ February 2015, Edmonds Community College

Agency Referring Applicant (if any): _________________________________________ APPLICANT INFORMATION Name: (First, Middle, Last) Current Address: City:

State:

ZIP Code:

Aliases/Maiden Name:

Sex: M

or

F

Soc Security Number:

Date of Birth:

Age:

Cell phone:

Alternative phone:

Email:

Emergency Contact:

Relationship:

Phone:

Veteran?

Tribal Affiliation? _____ Yes _____ No

Race/Ethnicity:

_____ Yes _____ No

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:

TANF Grant/month? $

CSO Office:

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

175% Federal Guideline

Persons in family/household

CATCH Income Eligibility

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$20,107.50 $27,142.50 $34,177.50 $41,212.50 $48,247.50 $55,282.50 $62,317.50 $69,352.50

For families/households with more than 8 persons, add $7,035.00 for each additional person.

$7,035.00

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To be eligible for CATCH, family taxable income cannot exceed 175% of the current Federal Poverty Level based on the preceding year. Copies of official federal tax records for the preceding year may be required for verification.

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CATCH APPLICATION CATCH INCOME ELIGIBILITY Monthly family gross income: $

Are you employed:

___ Yes

How many hours/week

If yes-- Employer:

___ No

_______

wage per hour $_________ Current receiving unemployment benefits:

Have you received unemployment benefits in the last 24 mo?

___ Yes ___ No

___ Yes

Other sources of income? (child support, SSDI, etc)

___ No

Are you enrolled in any of these programs? Check all that apply _____ _____ _____ _____ _____

Opportunity Grant TRIO Grant Workforce Investment Act WorkFirst/TANF BFET (Basic Food Employment and Training)

HOUSING INFORMATION Do you rent?

House _______

apartment ________

Is the lease in your name? _____ Yes _____ No

Amount of rent or mortgage you pay: $

If no, please describe your current living situation:

Do you have subsidized or low-incoming housing? _____ Yes _____ No

If yes, enter your portion of rent: $

Please list sources of funding you will use to pay for rent obligations while in the CATCH program:

PERSONAL HISTORY INFORMATION If you are a man ages 18-25 and living in the United States, then you must register with Selective Service. It’s the law.

Have you registered for the selective service? _____ Yes _____ No _____ Not Applicable

Have you ever had any contact with Child Protective Services (CPS) or Adult Protective Services (APS) anywhere in the United States, including Washington? Contact with Child Protective Services and Adult Protective Services refers to any involvement with either agency on any level, and is not limited to being the subject of an investigation. _____ Yes _____ No If yes, please describe when the contact occurred, where it occurred and the nature of the involvement you had with CPS or APS, including whether or not there was any finding reached against you.

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BACKGROUND CHECKS As required to apply for Nursing Assistant Certification in Washington State and a condition of employment in healthcare, 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 or suspended 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 jurisdiction? If yes, please explain:

_____ Yes

_____ No

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

PERSONAL & FAMILY NEEDS AND SUPPORT SYSTEMS Marital Status:

____ Single

____ Married

____ Separated

Number of children under age 18 in your family:

____ Divorced

Number of family in household: _______

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

Are you physically able to: Do you have active health problems that could interfere with your schooling or healthcare employment? _____ Yes _____ No If yes, please explain:

Do you smoke? ___Yes ___ No

Stay on your feet for 8 hours?

_____ Yes _____ No

Lift 50 pounds?

_____ Yes _____ No

Drag 100 pounds?

_____ Yes _____ No

Are you pregnant? ___Yes ___ No

Smoking is not permitted inside healthcare facilities and is no longer allowed on the grounds of most. Healthcare facilities must provide an overall healthy environment to patients and visitors and secondhand smoke has been proven hazardous to people’s health. For those needing to quit, help exists so please inquire with staff.

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, substance abuse, legal or court dates?)

How do you plan to travel to class:

_____ Car

_____ Bus

_____ Other

CATCH APPLICATION

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EDUCATIONAL BACKGROUND High School Diploma: _____ Yes _____ No

Name/Location of High School:

Date earned:

If no, highest grade completed: __________ Did you earn a GED? _____ Yes _____ No

Name/Location of granting institution:

Date earned:

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:

Dates:

Type of Training:

Completed? _____ Yes _____ No Name of School: Dates:

Type of Training:

Completed? _____ Yes _____ No Name of School:

Dates:

Type of Training:

Completed? _____ Yes _____ No

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:

Supervisor:

Reason for leaving:

Job Title:

Dates:

Supervisor

Reason for leaving:

Job Title:

Dates:

Supervisor

Reason for leaving:

Name/Location of Employer:

Name/Location of Employer:

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CATCH APPLICATION PERSONAL REFERENCES Please provide the names of two local individuals (supervisor, case manager, pastor, landlord, etc. ) besides family or relatives, whom we can contact for a personal character reference. Name:

Street address: City: State: Name:

Street address: City: State:

Phone:

Occupation:

Email:

Years known:___________ How do you know this person:

Phone:

Occupation:

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 accepting immediate employment.

AUTHORIZATION 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 HPOG to be selected through a lottery system. Those not selected through the lottery will not be able to participate in HPOG, but will be able to enroll in any other services 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 governmental entity and law enforcement agency.

Signature_____________________________________________________________

Date ______________

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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CATCH is here! #24 Gateway Hall

CATCH office is in Gateway Hall-2nd Floor 6600 196th St SW, Lynnwood, WA Next to the ice skating rink Parking is available in front of the building Keep this page for future reference

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CATCH Staff Offices-Heather Sipple 2nd Floor, Liberty Hall (#16 above) Everett, WA

Keep this page for future reference