WORKFORCE DEVELOPMENT AND ECONOMIC STABILITY

RAPID RECOVERY AND REEMPLOYMENT (R3)

INTAKE 
BHC C ’s Rapid Re co ve ry and Re e mplo yme nt (R3) Pro gram is a unique opportunity that allows students or community
members impacted by the COVID-19 economic downturn to get back in the game with possible financial support. Eligible
participants may have access to full tuition and materials scholarships. T hese short-term trainings will allow a student to study
over a shorter period of time, develop skills in a field, and earn an industry-recognized credential, which makes them employable
quicker. 

Eligibility

Must be 18 years of age to participate in any R3 Program

Must be a U.S Citizen, Permanent Resident, Asylum/Refugee
Must be unemployed, under employed, or new to the workforce

Students will be required to meet attendance and other requirements to access all funding opportunities. 

T hrough this program, candidates will receive specialized training, career-planning and placement services leading to employment
opportunities. R3 is designed to support and advance student outcomes in the areas of IT, and Healthcare.

DEMOGRAPHIC INFORMATION
 1

First Name *

Garry

Last Name *

Deroy

Street Address *

444 Harrison Avenue

City *

Boston

State *

Ma

Zip Code *

02118
 7

Phone number *

(617)279-7109

Is this Phone Number one of the following (If number is a cell number, you may receive
text messages with updates) *

Home

Cell

Work

Ot her

Email address *

garryderoy37@gmail.com

10

Date of Birth
*

2/16/1968

11

Please select your gender *

Woman
 Man

Non-binary

Prefer not to say

Ot her

12

Military Status *

None

Act ive Dut y/Current ly Serving

U.S. Vet eran

Reserve/Guard

13

Are you a current or former Adult Basic Education or Transitions to college student with
Bunker Hill Community College? *

Yes

No

14

Please select your Race/Ethnicity *

American/Alaskan Nat ive

Asian
 Black or African American

Cape Verdean

Hispanic/Lat ino

Hawaiian/Pacific Islander

Whit e

Mult iracial

Ot her

Eligibility and Acceptance (Please Read)

BHCC’s Rapid Recovery and Reemployment (R3) Program is a unique opportunity that allows students or community
members impacted by the COVID-19 economic downturn to get back in the game with possible financial support.
Eligible participants may have access to full tuition and materials scholarships. These short-term trainings will allow
a student to study over a shorter period of time, develop skills in a field, and earn an industry-recognized credential,
which makes them employable quicker. Students will be required to meet attendance and other requirements to
access all funding opportunities. R3 funding is not guaranteed to any student, funds are given based on
greatest need, program, and funding availability.

15

Please select your age group *

18-24

25-35

36-50

50+

16

Are you working part time making less than 17.00 per hour? *
 Yes

No

17

Are you new to the workforce? (New high school graduate, changing careers, new to the
United States) *

Yes

No

18

Which of the following best describes your current employment status? *

Employed

Unemployed

Volunt eer

Ret ired

Disabled

19

What is your household size? *

3
 4

7 or more

20

What is your total household income? *

Less t han $10,000

$10,000 to $19,999

$20,000 to $29,999

$30,000 to $39,999

$40,000 to $49,999

$50,000 to $59,999

$60,000 to $69,999

$70,000 to $79,999

$80,000 to $89,999

$90,000 to $99,999

$100,000 to $149,999

$150,000 or more
 21

Are you legally eligible to work in the U.S.? *

Yes

No

FINANCIAL INFORMATION

22

Have ever you received a Pell grant? *

Yes

No

I don't know

23

Are you collecting any of the following? *

I don't
Yes No know

Food
Stamps/EB
T

Transitional
Assistance
(Cash
Benefits)
 I don't
Yes No know

SSI

Any housing
subsidy

EDUCATIONAL INFORMATION

24

Please indicate the highest level of education completed *

Less t han High School Diploma or Equivalency

High School Diploma/GED/HiSet or Equivalency

Some College

Cert ificat e

Associat e Degree

Bachelor's Degree

Mast er's Degree

Ph.D./Doctorial Degree

Ot her

25

Have you taken courses at BHCC previously? *

 Yes

No

PROGRAM SELECTION

26

Program of Interest  *

CNA/Home Healt h Aide

Emergency Medical Technician (EMT )

Pharmacy Technician

Phlebotomy

EKG

Vet erinarian Assist ant

Dent al Assist ant

Medical Int erpret ing

Marine Technician

Cybersecurit y Training Cert ificat ion

Cisco Cert ified Net work Associat e (CCNA)

CompT ia A+

Google IT Support Specialist

PC Hardware
PROGRAM REQUIREMENTS -- HEALTHCARE

27

Can you commit to 80 percent of class attendance? *

Yes

No

28

Are you able to commit to a full time program, which includes 15+ hours of class and
study time a week? *

Yes

No

29

For Pharmacy Tech Students Only, have you done the BHCC English & Math
Assessments?

To access these assessments please visit:

English Self-Guided Placement

Link: https://bunkerhillcc.co1.qualtrics.com/jfe/form/SV_ 0uiaV4zc3hRLvBY

Math Accuplacer Test Link: https://www.registerblast.com/bhcc/Exam/List *

*If you are not a Pharmacy Tech student please select Not Applicable

Yes

No
 Not Applicable

30

Do you have the following vaccination requirement? *

Programs within healthcare require the following vaccinations

Yes No Pending Option 7

COVID-19
Vaccination
1

COVID-19
Vaccination
2

COVID-19
Booster

Current Flu
Shot

MMR

Hep B (2
doses)

TB

31

Vaccinations Continued... *
 Yes No Pending

TdaP

Varicella

Current
Physical
(Within 1
Year)

32

Once you complete your course work and job readiness/placement activities you will be
required to prepare for certification. Can you commit to completing this certification
process, within 90 days? *

Yes

No

33

The R3 requirements for program completion include the following:

Job Readiness Workshops (resume, Linkedin, etc)

Job Placement Services (interviews, interships, etc)
Bi-Weekly Check-In Meetings

Can you commit to attending these job placement support activities? *

Agree

Do not Agree
 34

As a prospective or current employee, subcontractor, volunteer, license applicant or

current licensee, I understand that a CORI check will be submitted for my personal
information to the DCJIS. I hereby acknowledge and provide permission to Bunker Hill
Community College to submit a CORI check for my information to the DCJIS. This
authorization is valid for one year from the date of my signature. I may withdraw this
authorization at any time by providing Bunker Hill Community College with written notice
of my intent to withdraw consent to a CORI check. As a prospective or current
employee, subcontractor, volunteer, license applicant or current licensee, I understand
that a CORI check will be submitted for my personal information to the DCJIS. 

I hereby acknowledge and provide permission to Bunker Hill Community College to

submit a CORI check for my information to the DCJIS. This authorization is valid for one
year from the date of my signature. I may withdraw this authorization at any time by
providing Bunker Hill Community College with written notice of my intent to withdraw
consent to a CORI check. *

Agree

Disagree

Please complete this section before you submit the form.

35

How did you hear about the R3 Program? *

*If "ot her" please specify

Email

BHCC Websit e

Own int ernet search

Social Media

Family or Friend
 Employer

College Advisor

Career Cent er (Mass Hire, DTA, et c.)

Job Training Program

Ot her

36

Please use this section to upload your most recent resume (if available)  *

Upload

Do not have a resume

37

When submitting this survey, you confirm you are aware of the following conditions:

1. Registration submitted by you is to facilitate class capacity.

2.  All private information filled in this survey is only ever shared with the Workforce
Development Division and funders due to funding purposes. This data is required
to be provided in order to maintain the grant funding and will only be used for the
purposes just described.
3. Given the limited seats available, submitting this registration form will not
guarantee final enrollment.
4. Hybrid mode of online learning may be available for some courses, but is not
available for all courses.
5. During next 3 years, students must be employed in area of training within the state
of Massachusetts.

Agree
 Disagree

38

Student certifies that all the information provided by you is correct and truthful. *
Please t ype your full name and submit form.

Garry Deroy

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