Compassionate Caregivers Enrollment Form

Applicant Information

• 
  First Name*
  
  

• 
  Middle Name
  
  

• 
  Last Name*
  
  

• Are you COVID Vaccinated?*
  YesNo

• Date of Birth*
  You must be at least 18 years old to be eligible for this program.
  

Contact Information

• 
  Street Address*
  
  

• 
  Address Line 2
  
  

• 
  City*
  
  

• 
  State / Province / Region*
  
  

• 
  Zip / Postal Code*
  
  

• 
  Country*
  
  

• 
  Primary Phone*
  
  

• 
  Alternate Phone
  
  

• 
  Email*
  
  

• 
  Preferred Language*
  
  

• Communication assistance required?*
  YesNo

Emergency Contact Information

• 
  Emergency Contact's First Name*
  
  

• 
  Emergency Contact's Last Name*
  
  

• 
  Emergency Contact's Phone*
  
  

• 
  Emergency contact's relationship to contact?*
  
  

Application Questions

• 
  Briefly share how the COVID pandemic has affected your ability to seek and maintain meaningful employment.
  
  

• 
  Compassionate Caregivers assists participants by linking them with training to become Certified Nursing Assistants and Geriatric Nursing Assistants. Briefly share why you are interested in this training.
  
  

• The training is virtual and requires participants to have a laptop and access to WiFi. Do you have these items?*
  Check all that apply.
  I have a working laptopI have access to WiFi

• The training is 5 hours a day, 5 days a week and lasts 6-10 weeks. Missing a training session may make you ineligible to receive certification. What barriers or issues do you foresee with completing the training?*
  Check all that apply.
  ChildcareScheduling conflict with current employmentChallenges working with technology/digital devices

• Which services do you need assistance with?*
  Check all that apply.
  Occupational trainingHousingFoodBehavioral healthFinancial empowermentLegal services

• 
  Are there other services that we might be able to assist with?
  
  

• What professional skills can we help you build?*
  Check all that apply.
  Resume preparationInterview skillsMaintaining professional presentation and appearance

Demographic Information

• Gender*
  Female/Female IdentifyingMale/Male IdentifyingNon-Binary

• Marital Status*
  Single (never married)Married/Domestic partnershipWidowedDivorcedSeparated

• Race/Ethnicity*
  Black/African AmericanWhite/CaucasianAsian (not Pacific Islander)Hispanic/Latino(a)Native American/Native AlaskanHawaiian Native/Pacific Islander

• Employment Status*
  Full-timePart-timeTemporary full-timeTemporary part-timeUnemployed

• Are you a military Veteran or actively serving?*
  YesNo

• Do you have children of your own ages 0-17 who reside in your household?*
  YesNo

• Do you have children of your own ages 0-17 who reside outside of your household?*
  YesNo

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