Apprenticeship Program | The Health Collaborative

Name*

First Last

Street Address or P.O. Box*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Email*

Are you 18 years of age or older?*

Yes
No

If NO, are you 17 years old AND have completed a state recognized pre-apprenticeship?

Yes
No

Do you have a high school diploma or equivalency?*

Yes
No

If NO, what is your expected high school graduation date?

Have you completed a WorkKeys Applied Math Assessment? What are your scores?*

Please note: this information will be verified.

Have you completed a WorkKeys Graphic Literacy Assessment? What are your scores?*

Please note: this information will be verified.

Have you completed a WorkKeys Workplace Documents Assessment? What are your scores?*

Please note: this information will be verified. Places where you can take WorkKeys Assessments include: Mercy Neighborhood Ministries, Urban League and Community Action Agency. For a complete listing of additional places, please visit http://www.act.org/content/act/en/products-and-services/workkeys-for-job-seekers/shared/test-site-locator-form.html.

Will you be able to successfully pass a drug screening?*

Yes
No

Will you be able to successfully pass a background check?*

Yes
No

For a list of disqualifying offenses, please copy & paste the following link into your browser in a new tab: https://healthcollab.org/wp-content/uploads/2019/04/ConvictionDisqualifiers.pdf

How did you hear about the Apprenticeship Program?*

Equal Employment Opportunity Information (optional)

The Health Collaborative is an equal opportunity employer that is committed to a program of recruitment of females, minority group members, individuals with disabilities, and qualifying veterans. In order to comply with governmental reporting requirements, we request that you supply the information below. This information is voluntary and will in no way effect the processing of your application or your consideration for employment. THE HEALTH COLLABORATIVE COMMITS TO THE FOLLOWING EQUAL OPPORTUNITY PLEDGE: The recruitment, selection, employment, and training of apprentices shall be without discrimination because of race, color, religion, national origin, age, or sex. The Health Collaborative shall take affirmative action to provide equal opportunity in apprenticeship and will operate the apprenticeship program as required under Title 29 of The Code of Federal Regulations, Part 30; Ohio Administrative Code 5101:11; and the equal employment opportunity regulations of the State of Ohio.

Gender

Male
Female
Other
I prefer not to answer

Race/Ethnicity

Hispanic or Latino
White (not Hispanic or Latino)
Black or African American (not Hispanic or Latino)
Native Hawaiian or Other Pacific Islander
Asian
Two or more races
I prefer not to answer

Veteran Status

I identify as one or more of the classifications of Protected Veteran
I am not a Protected Veteran
I prefer not to answer

Disability Status

Yes, I have a disability (or previously had a disability)
No, I don't have a disability
I prefer not to answer