CNA and Community Health Interest Form

Education and Workforce: Healthcare Training Interest Form

Community Health Program: Training, certification, Paid internship, and employment assistance)
Thank you so much for your interest in our Community Healthcare Program! Here are some things you should note before you complete this interest form:
- There are two programs under our Community Healthcare component:
  - Certified Nursing Assistant (Ages 18-24)
    
    Classes are from 10am-1p
    
    Provides professional development, skills trainings, CNA licensing, certifications
    
    Paid internship to build experience before employment
    
    Career placement services
    
    You must be willing to complete a drug screen and be vaccinated against COVID-19, have an up-to-date physical, and all other vaccinations as required for health-based jobs by New York State
  - Summer Youth Employment Program (Ages 16-24)
    
    Summer employment
    
    Career Placement services & more
- All of our programs are tuition-free and only cost your time!
You will be contacted by the Program Lead once your submission is recieved for an interview.
What program are you applying for?*
What is your name?*

First NameLast Name
What are your pronouns?

She/HerHe/HisThey/ThemOther
Date of Birth

MonthDayYear
Date
Age Days
Age
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Are you a resident of one of the five boroughs (Manhattan, Brooklyn, Bronx, Staten Island, Queens)?

ManhattanBronxBrooklynQueensStaten IslandNone of the above
Are you currently employed?

YesNo
Unfortunately, you do not meet the enrollment requirements below:
- Must be between the ages of 18-24 (16 for SYEP) by the start of program
- Must reside within the five boroughs
If you feel you have reached this message in error, please contact us at 646-381-9349.

Thank you.
If you are 17 or younger, do you have your working permit ("salmon colored" working papers)?

YesNo
Are you eligible for employment in the United States?

YesNo
How did you find out about our program?*
Referral Program Name
Please share the name of the staff that referred you from the program you named above
Do you already have a diploma?
In addition to industry standards, most health care positions require a COVID-19 vaccination. Which of the following applies to you?

I am fully vaccinatedI am not vaccinated and do not wish to be vaccinatedI have received at least one doseNot currently vaccinated, but I am willing to get vaccinated
Please upload your resume

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Education and Workforce: Healthcare Training Interest Form