At Risk Program Application

Student Application
Summer Youth Program

To qualify, participants must be experiencing one or more of the following:
- Financial Barriers (Trouble paying for basic needs like bills, clothes, or supplies)
- School attendance issues (Problems getting to school or missing school often)
- Non-supportive home-life (Limited support at home)
- Food insecurities (Not always having enough food)
- Juvenile record (Past involvement with the juvenile justice system)
- First-Gen student mindset (Being the first in their family to plan for college or career training)
- Skill deficiencies (Needing help building basic life, school, or job skills)
- Lack of a support system (Not having a strong support system or trusted adults to help)
- Transportation barriers (Difficulty getting transportation to school, work, or activities)
This facility is an equal opportunity employer and fully subscribes to the principles of Equal Employment Opportunity. It is the policy of this facility to provide employment, compensation, and other benefits related to employment based on qualifications, without regard to race, color, religion, national origin, age, sex, veteran status or disability, or any other basis prohibited by federal or state law. As an equal opportunity employer, this facility intends to comply fully with all federal and state laws, and the information requested on this application will not be used for any purpose prohibited by law. Disabled applicants may request any needed accommodation.
Student Name:*

First NameLast Name
Date of Birth:*
Student Phone Number:*
Please enter a valid phone number.
Are you 16 years or older?*

YesNo
Personal Email Address:*
By providing your email, you agree to be added to our marketing list to receive updates, promotions, and news; you can unsubscribe at any time.
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ethnicity:*
High School (now attending)*
Grade/Year in School*
County your school is in*
Name of Principal and/or Superintendent
Emergency Contact: (Parent or Guardian)
Name:*

First NameLast Name
Cell Phone:*
Relationship:*
Daytime Phone:
Do you have reliable transportation?*

YesNoUnsure
Are you CPR certified?*

YesNo, but I would like to attend a CPR certification classNo, and I am not interested in attending a CPR certification class
Which of the following apply to you? (check all that apply) For more information about these options please go to the top of the page.*

Financial BarriersSchool attendance issuesNon-supportive home-lifeFood insecuritiesJuvenile recordFirst-Gen student mindsetSkill deficienciesLack of support systemTransportation barriers
Which career(s) would you be interested in? (Description of each position listed below) Please choose your top 3 you would be interested in.*

NursingRadiologyHuman ResourcesFiscal Services/AccountingPatient ExperienceFood and NutritionPatient AccessOT/PT
Career Pathways:

Department: Nursing

Position: Nurse Assistant

The Nursing Assistant performs designated tasks to provide care for patients under the direction and supervision of a Registered Nurse or Licensed Practical Nurse.

Department: Radiology

Position: Radiologic Technologist Tech Aide

Provides assistance for health care services. Provides appropriate patient care and recognizes patient conditions essential for successful completion of the procedure.

Department: Human Resources

Position: HR Coordinator/ Assistant

Under the general direction and supervision of the Chief Human Resources Officer and with a direct working relationship with the Human Resources Specialist, the Assistant is responsible to provide a variety of administrative and administrative-related support services functions.

Department: Fiscal Services/Accounting

Position: Staff Accountant

Assists the Assistant Controller and Controller in performing various accounting functions of Memorial Hospital and associated entities.

Department: Patient Experience

Position: Patient Experience Specialist

The Patient Experience Specialist enhances the patient experience through exceptional customer service, efficient coordination of clerical and registration activities, and support for access to clinic services. Demonstrates professionalism, adaptability, and respect while upholding the organization’s mission and serving as a patient advocate.

Department: Food and Nutrition

Position: PM Cook

The primary responsibility of the PM Cook is to prepare and serve foods in a sanitary manner to preserve nutritional quality, comply with diet orders and meet needs of facility.

Department: Patient Access

Position: Patient Access Coordinator

Registers and pre-registers patients for hospital, outpatient, and emergency services. Verifies medical, demographic, and financial information to ensure accurate billing and regulatory compliance. Supports nursing staff with clerical duties, maintains patient records, verifies insurance, and manages payments and inventory while providing professional communication with patients and families.

Department: OT/PT

Position: Occupational Therapist Assistant

Assists the Occupational Therapist with patient evaluation, treatment planning, and therapy activities to improve mobility and reduce pain. Supports exercise instruction and demonstration and provides therapy services according to prescribed treatment plans and established occupational therapy practices.
Please click on the link below to fill out the required Workforce Innovation & Opportunity Act) WIOA application.

WIOA Questionnaire Application

Next Steps:

1. Please complete the student application that is attached to this form.

2. Please click on the link above to complete the WIOA questionnaire.

3. Once both applications are completed WIOA and Memorial Hospital will be in contact with you regarding further information.
Today's Date:*
EMPLOYMENT UNDERSTANDING
I HEREBY CERTIFY that the answers given by me to the above questions and statements are true and correct and hereby voluntarily authorize this facility to contact references, past or present employers, persons, schools, law enforcement agencies, and any other sources of information which may be relevant to my application for employment. Further, I release from all liability or responsibility all persons, companies, or corporations supplying such information. I voluntarily grant this release to support my application for employment at Memorial Hospital, Memorial Medical Clinics & Hancock County Senior and Childcare Services. I agree to inform the facility of any special concerns I may have related to information that may be discovered during this investigation in the space below. I further understand that all information and documents acquired by Memorial Hospital, Memorial Medical Clinics & Hancock County Senior and Childcare Services will be maintained as confidential by the facility and that the facility will not release such information to me. It is understood and agreed that any misrepresentation, false statement, or omissions by me in this application will be sufficient reason for rejection of my application or for dismissal at any time during my employment, without liability to this facility.

I further understand that my employment is at will and that either party is free to terminate the employment relationship at any time without cause. I also understand that no representative of the facility has the authority to enter into any agreement for employment for any specified period of time and that this facility is not guaranteeing employment for anyone. No employment contract is created by virtue of my being hired by this facility. I have read, understand, and agree with the above statement.

If employed, I agree to abide by all of the work and safety rules of the facility. If employed, I will be required to complete an Employment Verification Form (I-9). I agree to any and all pre-placement assessment(s) as may be deemed necessary by Memorial Hospital, Memorial Medical Clinics & Hancock County Senior and Childcare Services, and further, understand that my employment is contingent upon my completion of the facility pre-placement assessment. I understand that this facility is committed to maintaining a drug-free workplace. I am aware that the facility may require a drug test as part of the hiring process. Also, if employed, I realize that the facility may conduct post-accident and reasonable suspicion drug and/or alcohol testing of its employees. I have read, understand, and agree with the above statement.

By signing below you acknowledge that you have read, understand, and agree with the above statement.
Student Signature:*

Clear
Parent or Guardian Signature (Student under 18 years of age)*

Clear
Should be Empty:

Student Application

Emergency Contact: (Parent or Guardian)

EMPLOYMENT UNDERSTANDING