KP LAUNCH PROGRAM APPLICATION (PLEASE PRINT IN BLUE OR BLACK INK)

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1 KP LAUNCH PROGRAM APPLICATION (PLEASE PRINT IN BLUE OR BLACK INK) Please complete and submit the following documents with all necessary signatures: Program Application (signature required on page 4 of application) Self-identification form (page 5 of application) Intern Personal Statement (attach typed copy; prompt located on page 3 of Info Packet) Parental Consent Form (if under the age of 18 by June 1, 2016, parent signature is required) 2 Letters of Recommendation (attach typed copies to application) Resume (attach typed copy) Applications missing any items listed above PERSONAL are incomplete, DATA and the applicant will not be considered. NAME (LAST) (FIRST) (MIDDLE) TODAY S DATE ADDRESS (NUMBER) (STREET) (UNIT #) HOME PHONE ( ) ALTERNATE PHONE ( ) CITY STATE ZIP CODE ADDRESS: Will You Be 16 Years Of Age Or Older On June 1, 2016? Will You Be Over The Age Of 20 By June 1, 2016? Are You Presently 18 Years Of Age Or Older? IF NO, WILL YOU BE 18 YEARS OF AGE ON JUNE 1, 2016? Have you ever been employed by Kaiser Permanente or any other Kaiser organization? IF YES, PLEASE SPECIFY WHICH LOCATION, DEPARTMENT AND ORGANIZATION: EMPLOYMENT DURATION POSITION HELD NAME USED Are you or have you ever been a Kaiser Permanente volunteer? YES, WHEN & WHERE: NO Do you have a parent, stepparent, or legal guardian working for Kaiser Permanente? IF YES, PLEASE SPECIFY YOUR RELATIONSHIP WITH THAT PERSON AND WHICH DEPARTMENT HE OR SHE WORKS IN: If hired, you will be required to furnish proof that you are legally authorized to work for Kaiser Permanente in the United States. Please visit the following website to review acceptable employment eligibility document: Can you furnish such proof? YES NO PAGE 1

2 CURRENT SCHOOL NAME: EDUCATION INFORMATION CITY OF CURRENT SCHOOL: GRADE YOU WILL COMPLETE THIS YEAR: 10 TH GRADE 11 TH GRADE 12 TH GRADE 1 ST YEAR COLLEGE/UNIVERSITY Company Name, Address & Phone EMPLOYMENT / VOLUNTEER / LEADERSHIP EXPERIENCE LIST CURRENT AND PREVIOUS WORK EXPERIENCE (INCLUDE VOLUNTEER WORK AND/OR LEADERSHIP ACTIVITIES) Dates Employed Job Title And Duties Performed LANGUAGE PROFICIENCY (other than English) LANGUAGE: READ WRITE SPEAK AMERICAN SIGN LANGUAGE (SIGN) SKILLS Type of computer software skills: IN THE BOXES BELOW, INDICATE YOUR SKILL LEVEL USING THE FOLLOWING COMPUTER PROGRAMS: Beginning (B), Intermediate (I), or Advanced (A) Excel Word PowerPoint Access Publisher Adobe Photoshop Typing, words/minute: Other: List other skills, if any: PAGE 2

3 SPECIAL INTERESTS List Healthcare Pathways That You Would Like More Information About: Administration & Support Services Human Resources I.T. Clinical Positions In Preference Order, List Three Careers In Healthcare That Interest You The Most: TIME COMMITMENT WILL YOU BE ATTENDING SUMMER SCHOOL BETWEEN JUNE 2016 AND AUGUST 2016? YES NO WILL YOU BE ON VACATION OR OUT OF TOWN BETWEEN JUNE 2016 AND AUGUST 2016? YES NO ARE YOU PLANNING TO ATTEND A UNIVERSITY ORIENTATION OVER THE SUMMER? IF YES, HOW MANY DAYS DURING THE WORK WEEK, AND ON WHICH DAYS (IF KNOWN)? FAMILY BACKGROUND What are your parents /legal guardians educational background? PLACE AN X OR CHECKBOX BESIDES THE MOST APPLICABLE RESPONSE. DID NOT COMPLETE HIGH SCHOOL GRADUATED FROM HIGH SCHOOL OR ATTAINED G.E.D. COMPLETED SOME COLLEGE ASSOCIATE S DEGREE OR TRAINING/CERTIFICATE PROGRAM BACHELOR S DEGREE MASTER S, GRADUATE OR PROFESSIONAL DEGREE (MBA, MS, MD, PHD, ETC.) UNKNOWN PLACE AN X IN THIS BOX IF YOU RESPONDED ABOUT YOUR MOTHER S EDUCATION LEVEL ABOVE: YES NO MOTHER OR PARENT/GUARDIAN 1 What is the best estimate of your family s household income? (before taxes from all sources) FATHER OR PARENT/GUARDIAN 2 $20,000 - $35,000 $35,000 - $50,000 $50,000 - $65,000 $65,000 - $80,000 $80,000 - $95,000 $95,000 & higher How many people live within your household? OR MORE REFERRAL How Did You Learn About The KP LAUNCH Internship Program? COUNSELOR/TEACHER YOUTH PROGRAM (PLEASE SPECIFY): KAISER PERMANENTE VOLUNTEER SERVICES KAISER PERMANENTE EMPLOYEE (PLEASE SPECIFY): PRESENTATION KP LAUNCH WEBSITE OTHER: PLEASE SPECIFY: Have you been exposed to careers in health care before? YES NO IF YES, HOW? REFERENCES PLEASE LIST TWO PEOPLE (NON-RELATIVES) WHO CAN PROVIDE A GOOD RECOMMENDATION ABOUT YOUR CHARACTER AND WORK ETHIC. NAME PHONE NUMBER OCCUPATION HOW DOES THIS PERSON KNOW YOU? NAME PHONE NUMBER OCCUPATION HOW DOES THIS PERSON KNOW YOU? PAGE 3

4 APPLICANT STATEMENT TO THE APPLICANT: Kaiser Foundation Health Plan, Inc., Kaiser Foundation Hospitals (KFHP/H), KFHP/H s subsidiaries, Southern California Permanente Medical Group, and the Permanente Medical Group, Inc. ( Kaiser Permanente ) are equal opportunity and affirmative action employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability status Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. Kaiser Permanente provides applicants who have disabilities with reasonable accommodations to assist in the interview/hiring process. Applicants requiring accommodations should contact the human resources office. Kaiser Permanente is a smoke-free workplace. This document must be completed in its entirety before an offer of employment can be authorized. I UNDERSTAND THAT THE KAISER PERMANENTE LAUNCH INTERNSHIP PROGRAM GUIDELINES FOR ELIGIBILITY REQUIRE THAT I MUST BE A HIGH SCHOOL STUDENT OR A RECENT HIGH SCHOOL GRADUATE. IF I AM UNDER THE AGE OF 18, I MUST OBTAIN A WORK PERMIT AND THE CONSENT OF A PARENT OR GUARDIAN. I AM NOT ELIGIBLE FOR THIS PROGRAM IF I HAVE A PARENT OR LEGAL GUARDIAN EMPLOYED BY KAISER PERMANENTE. This application is submitted with the understanding that all job offers are conditional and will not be confirmed until satisfactory completion of a pre-employment health screening and urinalysis drug test. I hereby consent to such required screening and drug testing. I hereby authorize Kaiser Permanente to solicit all information relevant to this application. This authorization includes but is not limited to, my academic background, my references, and my employment history. If I am over 18, I also understand that I will be required to complete the Kaiser Permanente job application in addition to this application and that Kaiser Permanente will perform a criminal background check. I authorize and request all persons, schools, employers governmental, law enforcement and other agencies to release such requested information to Kaiser Permanente. I also understand that all job offers are contingent upon receipt of satisfactory verification of all of the above information including verification of my ability to perform the essential functions of the position that I have applied for. I certify that the answers I have provided above are true, correct and complete and that I have not knowingly withheld any facts. I understand any falsification, misrepresentation or omission of facts are sufficient reasons for disqualification from further consideration for employment or dismissal at any time during employment should I become employed at Kaiser Permanente. I also understand that if I am employed by Kaiser Permanente, my employment can be terminated at any time with or without cause and with or without notice. I understand that a copy of this document is available to me if I so desire. APPLICANT S SIGNATURE: DATE: PAGE 4

5 Voluntary Self-Identification of Disability Form CC-305 OMB Control Number Expires 1/31/2017 Page 1 of 2 Why are you being asked to complete this form? Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. i To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way. If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier. How do I know if I have a disability? You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities include, but are not limited to: Blindness Autism Bipolar disorder Post-traumatic stress disorder (PTSD) Deafness Cerebral palsy Major depression Obsessive compulsive disorder Cancer HIV/AIDS Multiple sclerosis (MS) Impairments requiring the use of a wheelchair Diabetes Epilepsy Schizophrenia Muscular dystrophy Missing limbs or partially missing limbs Intellectual disability (previously called mental retardation) Please check one of the boxes below: YES, I HAVE A DISABILITY (or previously had a disability) NO, I DON T HAVE A DISABILITY I DON T WISH TO ANSWER Your Name Today s Date

6 Voluntary Self-Identification of Disability Reasonable Accommodation Notice Form CC-305 OMB Control Number Expires 1/31/2017 Page 2 of 2 Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment. i Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor s Office of Federal Contract Compliance Programs (OFCCP) website at PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

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