CATCH Grant

Application Packet
The CATCH Program provides expense-paid foundation training for select health care professions at Edmonds and Everett Community Colleges, preparing students for success in a wide variety of well-paying, in-demand health professions

Student Checklist
 Complete Application

Drop-off, mail, fax or email packet to CATCH office Physical Address: 6600 196th ST SW, Lynnwood, WA (Next to Ice Arena) Mailing Address: Edmonds CC, CATCH Grant, 20000 68th Ave W, Lynnwood, WA 98036 Fax: 425-640-1363 Email: catch.admin@edcc.edu Phone: 425-640-1361
After eligibility review CATCH staff will contact you to schedule an Assessment Attend 4 hour Information/Assessment session at CATCH office at Edmonds CC.

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The Health Profession Opportunity Grant (HPOG)/CATCH program is a demonstration project funded by the Administration for Children and Families (ACF) in the U.S. Department of Health and Human Services (HHS). The primary goals of this project are to: 1. Provide education and training to low-income individuals for occupations in healthcare that pay well 2. Learn what kinds of education and training programs work. In order to learn what works, we are conducting a study requiring every person eligible for CATCH/HPOG to be selected through a lottery system. Those not selected through the lottery will not be able to participate in CATCH, but will be able to enroll in any other college or community services or programs for which they are eligible.

Staff Use only: WorkFirst TANF ___ TANF Eligible ___ IRP approval ___ E-JAS Referral BFET ___ Food Stamp approval ___ BFET/DSHS approval ___ Working Connections Other income eligibility ___ WIA ___Opportunity Grant or TRIO ___ Income (175% Federal Guide) _____ High School Diploma or GED

___ Permanent resident, eligible for financial aid

This document was supported by Grant 90FX0025-02-00 from the Administration for Children and Families, U.S. Department of Health & Human Services (HHS). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HHS.

2013. Last) Current Address: City: Aliases/Maiden Name: Soc Security Number: Cell phone: Emergency Contact: Veteran? _____ Yes _____ No Date of Birth: Alternative phone: Relationship: Tribal Affiliation? _____ Yes _____ No BASIC ELIGIBILITY US Citizen? ____ Yes ____ No If not. Edmonds Community College ___ November 12.CATCH Grant Application 2013-2014 Name:_________________________________________ Application Date:__________________ Preferred CATCH Start Date: ___ September 3. 2013. Permanent Resident Card #: Languages Spoken: Place of Birth: Exp Date: Age: Email: Phone: Race/Ethnicity: State: ZIP Code: Receiving TANF cash benefits? ___Yes ___ No TANF Grant/month? $ If so. Middle. Edmonds Community College ___ January 6. how long: CSO Office: Do you receive Basic Food (Food Stamps) ___ Yes ___ No . 2014. Everett Community College ___ February 10. Edmonds Community College Agency Referring Applicant (if any): _________________________________________ APPLICANT INFORMATION Name: (First. 2014.

add $7. Have you registered for the selective service? _____ Yes _____ No _____ Not Applicable Have you ever had any contact with Child Protective Services (CPS) or Adult Protective Services (APS) anywhere in the United States. then you must register with Selective Service.282. etc) Persons in family/household 1 2 3 4 5 6 7 8 175% Federal Guideline $20. $7. please describe when the contact occurred.CATCH Income Eligibility To be eligible for CATCH. SSDI. enter your portion of rent: $ Please list sources of funding you will use to pay for rent obligations while in the CATCH program: PERSONAL HISTORY INFORMATION If you are a man ages 18-25 and living in the United States.50 $55. including whether or not there was any finding reached against you.50 $69.50 $34. CATCH APPLICATION CATCH INCOME ELIGIBILITY Monthly family gross income: $ If yes-. _____ Yes _____ No If yes.Employer: Current receiving unemployment benefits: ___ Yes ___ No Other sources of income? (child support. where it occurred and the nature of the involvement you had with CPS or APS.035.00 for each additional person.107.352. please describe your current living situation: Do you have subsidized or low-incoming housing? _____ Yes _____ No If yes. Copies of official federal tax records for the preceding year may be required for verification.50 $41.212.035.00 Are you employed: How many hours/week ___ Yes _______ ___ No wage per hour $_________ Have you received unemployment benefits in the last 24 mo? ___ Yes ___ No Are you enrolled in any of these programs? Check all that apply _____ _____ _____ _____ _____ HOUSING INFORMATION Opportunity Grant TRIO Grant Workforce Investment Act WorkFirst/TANF BFET (Basic Food Employment and Training) Do you rent? House _______ apartment ________ Amount of rent or mortgage you pay: $ Is the lease in your name? _____ Yes _____ No If no.50 For families/households with more than 8 persons. and is not limited to being the subject of an investigation.50 $48.177.317. including Washington? Contact with Child Protective Services and Adult Protective Services refers to any involvement with either agency on any level.50 $27.142.50 $62.247. It’s the law. family taxable income cannot exceed 175% of the current Federal Poverty Level based on the preceding year. .

entered a pleas of guilty. please explain: _____ Yes _____ No Other than any matter above. For those needing to quit. substance abuse. or will you need assistance in securing child care? Please describe Are you physically able to: Do you have active health problems that could interfere with your schooling or healthcare employment? _____ Yes _____ No If yes.gov Have you ever been convicted. no contest. For additional information about state requirements visit : http://www. Are you pregnant? ___Yes ___ No If so. young people or developmentally disabled persons? _____ Yes _____ No If yes. please explain: PERSONAL & FAMILY NEEDS AND SUPPORT SYSTEMS Marital Status: ____ Single ____ Married ____ Separated ____ Divorced Number of family in household: _______ Number of children under age 18 in your family: Ages of your children: If you have children of child care age. what is your plan for them while you are in CATCH? Do you already have child care in place. Healthcare facilities must provide an overall healthy environment to patients and visitors and secondhand smoke has been proven hazardous to people’s health.BACKGROUND CHECKS As required to apply for Nursing Assistant Certification in Washington State and a condition of employment in healthcare. is there any fact or circumstance involving you and your background that would call into question your being entrusted with the care. Due Date: ______________ **Being pregnant does not disqualify you from this program. please explain: Stay on your feet for 8 hours? Lift 50 pounds? Drag 100 pounds? _____ Yes _____ No _____ Yes _____ No _____ Yes _____ No Do you smoke? ___Yes ___ No Smoking is not permitted inside healthcare facilities and is no longer allowed on the grounds of most. please explain: Are you now subject to criminal prosecution or pending charges of a crime in any state or jurisdiction? If yes. guidance or supervision of vulnerable adults.doh.wa. CATCH conducts an in-depth criminal background check on each applicant. or a similar plea. Do you have any counseling appointments that would interfere with your schooling? Do you have other personal issues that could interfere with your schooling in the next few months? (domestic violence. help exists so please inquire with staff. or had prosecution or a sentence deferred or suspended as an adult or juvenile in any state/jurisdiction? _____ Yes _____ No If yes. legal or court dates?) How do you plan to travel to class: _____ Car _____ Bus _____ Other .

please list your first language: EMPLOYMENT HISTORY Do you currently work in a healthcare job? _____ Yes _____ No Have you ever worked in a healthcare job? _____ Yes _____ No Job title: Name/Location of Employer: Job title: Name/Location of Employer: Please list your most recent experience. Highest ESL class/level completed: ____________ Is English your first language? _____ Yes _____ No If not. classes or certificates since high school or GED diploma Name of School: Type of Training: Dates: Completed? _____ Yes _____ No Name of School: Type of Training: Dates: Completed? _____ Yes _____ No Name of School: Type of Training: Dates: Completed? _____ Yes _____ No Have you taken ESL classes (English as a Second Language)? _____ Yes _____ No If yes. highest grade completed: __________ Did you earn a GED? _____ Yes _____ No Date earned: Name/Location of granting institution: Do you have any outstanding student loan debts? _____ Yes _____ No If so. Include work experience. how much do you owe and name of school: Date earned: Name/Location of High School: Have you attended a Washington State College _____ Yes _____ No Date attended: ________ Student ID #: ______________________ Please list all training. volunteer or community service positions Job Title: Supervisor: Job Title: Supervisor Job Title: Supervisor Dates: Reason for leaving: Dates: Reason for leaving: Dates: Reason for leaving: Name/Location of Employer: Name/Location of Employer: .CATCH APPLICATION EDUCATIONAL BACKGROUND High School Diploma: _____ Yes _____ No If no.

pastor. Signature_____________________________________________________________ Date ______________ This document was supported by Grant 90FX0025-02-00 from the Administration for Children and Families. U.S. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HHS. Conduct background checks and to obtain any and all information needed to process my application. ) besides family or relatives. 2. but will be able to enroll in any other services or programs for which they are eligible. In order to learn what works. Learn what kinds of education and training programs work. community partners and any governmental entity and law enforcement agency. . Name: Phone: Email: Occupation: Years known:___________ How do you know this person: Street address: City: State: Name: Phone: Email: Occupation: Years known:___________ How do you know this person: Street address: City: State: CAREER GOALS AND EMPLOYMENT READINESS What interests you about a career in healthcare? Please state your job and career goals. How will the CATCH Program help you achieve these goals? Please list any obstacles coming up in the next nine months that might prevent you from completing this training and/or accepting immediate employment. I give Edmonds CATCH grant program permission to share necessary information with college staff at Edmonds Community College and Everett Community College. Department of Health and Human Services (HHS). I certify the information given is true and correct. case manager. etc. we are conducting a study requiring every person eligible for HPOG to be selected through a lottery system. whom we can contact for a personal character reference. landlord. The primary goals of this project are to: 1. Department of Health & Human Services (HHS). I have read the information contained in this application. Those not selected through the lottery will not be able to participate in HPOG.CATCH APPLICATION PERSONAL REFERENCES Please provide the names of two local individuals (supervisor. I authorize the Edmonds Community College CATCH Grant program to: 1. Provide education and training to low-income individuals for occupations in healthcare that pay well 2.S. AUTHORIZATION The Health Profession Opportunity Grant (HPOG)/CATCH program is a demonstration project funded by the Administration for Children and Families (ACF) in the U. By signing below.

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