The Rise Up Program Application
Please complete the form below. Information shared in this application will remain confidential and will be viewed only by program staff. You may save and continue your application at a later date if necessary. If you have any questions about the program or application, please contact edilma.rodriguez@goodwillsew.com.
Full Name
*
First Name
Last Name
Current Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email Address
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
How did you hear about the program?
*
Previous Participant
Manager
Email
Flyer
Other
If you heard about the program from a previous participant, what is their name?
Eligibility Requirements
Are you a current Ascension or TouchPoint employee in good standing?
*
Yes, Ascension
Yes, TouchPoint
Other Ascension contracted employer ( HSS, Trimedix, R1, etc)
No
Other
Do you identify as a single parent or caregiver?
*
Single parent
Caregiver to adult or child
Neither
Do you have a high school diploma, HSED, or GED?
*
Yes
No
Other
Which campus do you work at?
Spring Street
Wisconsin Ave
Mount Pleasant
Other
Do you identify as a person of color or minority?
*
Yes
No
I do not wish to provide this information.
What gender do you identify with?
Female
Male
I do not wish to provide this information.
Other
Household Information
How many people live in your household?
*
How many children (primary dependents) do you have?
*
What are their ages?
*
What is your total approximate household income for one year?
*
Career Interests and History
My job interests include: (select 2-3 that apply)
*
CNA (Nursing/MA/Patient Care Pathway)
Lab Assistant (Tech Pathway - Medical Lab Technician)
Pharmacy Technician (Tech Pathway)
Phlebotomist (Tech Pathway)
Respiratory Therapist (Patient Care Pathway)
Imaging (Patient Care Pathway)
Emergency Department (ED) Tech (Patient Care Pathway)
Other
What is your current job title?
*
Department
*
Date started:
*
-
Month
-
Day
Year
Date Picker Icon
What is your manager or direct supervisor's name?
*
Manager's phone number:
*
Manager's email address:
*
What is your current work status?
*
full-time
part-time
casual
How many hours do you typically work in a week?
*
What shift do you typically work?
*
1st shift
2nd shift
3rd shift
Please complete the chart to reflect your typical work schedule:
*
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Start
End
Education
What is your highest level of education?
*
High School, GED, or Equivalent
Some College (did not finish)
Some College, Certificate or Associates
Bachelor's Degree
Graduate Degree (master's) or higher
Have you participated in any school or training programs?
*
Yes
No
If yes, please list:
Do you have any licenses or certifications?
*
Yes
No
If yes, please list:
Assistance & Other Income
Your answers to these questions do not determine your program eligibility. Instead, they help us to understand how we can assist you if you are selected to participate in the program. Your answers to these questions are private and will not be shared outside of the program staff.
Are you currently receiving any public assistance benefits?
*
Yes
No
If yes, please list:
Are you or someone in your household receiving Social Security Income?
*
Yes
No
If yes, who and what kind?
Have you or are you currently serving in the military?
*
Yes
No
If yes, which branch and dates of service?
Are you the spouse of a veteran?
*
Yes
No
Have you experienced barriers to employment in the following areas?
What is your primary mode of transportation?
*
Car
Public Transportation
Friend/Family
Uber/Lyft/Taxi
Walk
Other
Do you have a driver's license?
*
Yes
No, never have
No, restricted or suspended
Do you have a criminal background?
*
Yes
No
Do you have regular access to internet and a computer or laptop with a web camera?
*
Yes
No
Other
Short Answer Question
Why do you want to be a part of this program? Please provide at least 4-5 sentences explaining.
*
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