CAREERS Health Care Aide Program (HCA) Application Form

Transcription

1 CAREERS Health Care Aide Program (HCA) Application Form Submitted by Grade School Alberta Education ID# - -

2 CAREERS Health Care Aide Programƒ Application Package Contents INSTRUCTIONS: Complete and/or attach the following in the order listed. Check each item off as you complete and/or attach it. Only completed application packages will be considered. Part I Personal Data Part II Information Relevant to Program Part III Work Skills and Employability Skills Part III Part IV Attachments A. Resume B. Statement of Marks Counselor must sign the copy from Alberta Education Extranet or from the school s report program. Include copy of Grade 9 marks as well as current grade 10 marks. If in grade 11, include grade 10 marks and current marks. Counselor should indicate current mark in each course or mid-term mark. C. Timetable D. Record of School Attendance E. Three Year High School Plan (signed by Counselor) Recommendation Forms A. Teacher B. Community Contact (Minister, Coach, Employer, Etc.) Part V HCA Coordinator Recommendation To be completed by the HCA coordinator following the review of the student s package. 2

3 Part I Personal Data Student Information Last First Middle Street City Postal Code Home Phone: ( ) Cell Phone: ( ) Birthdate Month = Day = Year = Grade: Social Ins. # Home Computer Address: Parent or Guardian Information Alberta Education # - - Parent or Guardian: Work Phone ( ) Street: (if different than above) Cell Phone ( ) City (if different than above) Health Information Postal Code Doctor Name Work Phone ( ) AHC # - Important Medical Information Name of 1 st Emergency Contact Day Phone ( ) Evening Phone ( ) Name of 2 nd Emergency Contact Day Phone ( ) Evening Phone ( ) Name of 3 rd Emergency Contact Day Phone ( ) Evening Phone ( ) Parental or Guardian Support I support involvement in the HCA program and agree to abide by all of the HCA program requirements for the above named student. Parent or Guardian Signature The information contained herein may be used by CAREERS: The Next Generation for career choice updates or to request further involvement with your program (i.e. video productions, success story quotes & statistical analysis). If you do not wish to be contacted please check here: 3

4 Part II Information Relevant To Program 1. What interested you to enroll in the Health Care Aide program? 2. What are your academic and/or educational goals for the future? 3. List, in order of preference, occupations in the health care industry you want to pursue as future career goals If selected for the health care aide program do you have any responsibilities or obligations for after work hours, weekends, or vacation periods that could interfere with your ability to commit to the summer internship? Yes No If yes, explain: 4

5 Are you willing to give up all part-time employment for the summer if selected for one of the summer internship experience? If no, explain: Yes No 5. Do you have a valid drivers licence? Yes No If no, when do you anticipate getting your licence? (mm/yyyy) Will you be able to arrange transportation to and from your work on a daily basis? Yes No 6. Do you have a valid Standard First Aid and CPR level C certificate? No Yes If yes: Expiry Date: 5

6 Part III Work Skills and Employability Skills 1. Identify your strongest work related skills and explain why these are your strongest. 2. Give examples of teamwork skills you show on a regular basis. 3. Describe at least 4 personal management skills and give an example of how you show each skill in your daily life. Example: initiative, integrity, honesty, responsible, set goals, manage time, accountable, etc. (refer to the Conference Board of Canada s Employability Skills 6

7 Part III E Three Year High School Plan In the chart below, check with an x in the box, the courses you are enrolled in for Grade 10 as well as the course you intend to take in Grades 11 and 12. For those students who are in Grade 11 or Grade 12 who intend to enroll in the program please check with an x in the box, the courses you are currently enrolled in. Using the blank spaces available, please add additional courses not on the list that you are enrolled in now and plan to take in the future years. Grade 10 Grade 11 Grade 12 English 10-1 English 20-1 English 30-1 English 10-2 English 20-2 English 30-2 Math 10C Math 20-1 Math 30-1 Math 10-3 Math 20-2 Math 30-2 Science 10 Math 20-3 Math 30-3 Social 10 Chemistry 20 Math 31 Social 13 Physics 20 Chemistry 30 Phys Ed. 10 Biology 20 Physics 30 CALM Science 20 Biology 30 Religion Social 20 Science 30 Art Social 23 Social 30 Drama CALM Social 33 Band Religion CALM Other: Phys Ed 20 Religion Other: Phys Ed 30 Other: Counselor s Name: and Signature: List your participation in school activities, athletics, community activities, or church activities. Indicate your 2 favorite school subjects and briefly explain skills learned in each one

8 Part IV A Teacher Recommendation This student is applying for the Health Care Aide program. The HCA Program and required summer internship requires dedication to the NorQuest College program as well as commitment to a full time position for the summer. This student will be responsible for learning many new skills, working with a mentor and the joy of working with the senior population and showing great respect to his/her employers. It is in the best interest of students, the school, and the community, that a student who takes part in off-campus education activities under the auspices of the school, be perceived in a positive manner. When assessing the eligibility of a student for a HCA Program and summer internship, it is important that we feel confident that our school is being well represented. To that end we are asking you to provide some information on the student identified below. This information will form part of the basis on which the student s eligibility for the HCA Program and Summer Internship will be determined by the employer. Thank you in advance for your frankness. The Health Care Aide program allows a student to graduate high school while earning a HCA Certificate from NorQuest College and gaining valuable clinical experience in the health care industry. Please indicate your perception of this student with respect to the following chart by placing a check mark ( ) on each line below the appropriate number. Poor Excellent 1. Attitude 2. Attendance 3. Punctuality 4. Work Habits (use of class time) 5. Ability to stay focused on a task 6. Ability to meet deadlines 7. Work quality 8. Ability to work as part of a team 9. Demonstrates respect 10. Demonstrates maturity 11. Demonstrates responsibility 12. Demonstrates initiative 13. Demonstrates common sense 14. Demonstrates problem solving ability 15. Demonstrates leadership Student Name Subject Teacher Name Phone ( ) Teacher Signature School I (do, cannot) recommend the above named student to be considered for enrollment in the Health Care Aide Program. 8

9 Part IV B Community Contact Recommendation This student is applying for enrollment in the Health Care Aide Program as well as Summer Internship in the Health Care Aide program. The Health Care Aide program allows a student to graduate high school while earning a HCA Certificate from NorQuest College and gaining valuable field experience in the health care industry. The HCA Summer Intern requires dedication and commitment to a full time job for the summer. This student will be responsible for learning many new skills, working with a mentor and the senior population and showing great respect to his/her employers. It is in the best interest of students, the school, and the community, that a student who takes part in off-campus education activities under the auspices of the school, be perceived in a positive manner. When assessing the eligibility of a student for a HCA Summer Internship, it is important that we feel confident that our school is being well represented. To that end we are asking you to provide some information on the student identified below. This information will form part of the basis on which the student s eligibility for enrollment in the Health Care Aide Program and a HCA Summer Internship will be determined by the employer. Thank you in advance for your frankness. Please indicate your perception of this student with respect to the following chart by placing a check mark ( ) on each line below the appropriate number. Poor Excellent 1. Attitude 2. Attendance 3. Punctuality 4. Work Habits (use of class time) 5. Ability to stay focused on a task 6. Ability to meet deadlines 7. Work quality 8. Ability to work as part of a team 9. Demonstrates respect 10. Demonstrates maturity 11. Demonstrates responsibility 12. Demonstrates initiative 13. Demonstrates common sense 14. Demonstrates problem solving ability 15. Demonstrates leadership Student Name Contact Name Phone ( ) Contact Signature School How do you know the student? I (do, cannot) recommend the above named student to be considered for enrollment in the Heath Care Aide program. 9

10 Part V: School-Based Health Care- Aide Coordinator Recommendation The School-Based HCA Coordinator through consultation with the student s Guidance Counsellor, should complete this form after reviewing the student s application package. Student Name: Is this student on track to graduate at the end of Grade 12? Yes No Does this student have a good record of attendance? Yes No Does this student have a good record of citizenship? Yes No Please note below any concerns you may have. I recommend that the above student be accepted as a candidate for the HCA Program and summer internship. Yes No HCA Coordinator Name: School: HCA Coordinator Signature Phone ( ) address: Fax: ( ) 10