Health Cadre Eligibility Form October 2023 Cohort I. Applicant InformationName(Required) First Last Email Address:(Required)Note: This is the primary email address that we will use to communicate with you. Enter Email Confirm Email Primary Phone Number(Required)Alternate Phone NumberAre you between the ages of 18 and 24?(Required)Only applicants between the ages of 18-24 are eligible to apply for this program. Yes Birthdate (Month/Day/Year)(Required)You must be at least 18 years old to apply. MM slash DD slash YYYY Do you live in Monterey County, CA?(Required)You must reside in Monterey County to be eligible for the Health Cadre program. Yes No Where do you live?(Required) Street Address Apt/PO Box City/Town State / Province / Region ZIP / Postal Code Check all that apply:(Required) I have not participated in an AmeriCorps program I have difficulty finding employment I am considered low-income I am unemployed and/or out of school I am or was justice-involved I am in or transitioning from foster care I am engaged with the mental health or substance abuse system None of the above apply to me Are you currently employed?(Required)YesNoIf yes, where are you employed? Have you ever had a job before?(Required)YesNoIf yes, please list the names of the businesses you've worked at: Have you ever participated in a job training program?(Required)YesNoIf yes, please list the name of the program(s): What is the highest grade you've completed?(Required)7th grade8th grade9th grade10th grade11th grade12th gradeGED/High School Equivalency DegreeSome collegeGraduated collegeDid you graduate High School?(Required)YesNoHow did you learn about the Health Cadre program?(Required) Monterey County Workforce Development Board Representative Flyer Social Media Teacher or Academic Advisor Presentation Other II. Photo ReleaseI agree that as a participant in the Monterey County Workforce Development Board’s programs and/or services, the use of any photographs taken that include my image or likeness may be used for any legal use including, but not limited to, publicity, copyright purposes, illustration, advertising, social media, and web content. Furthermore, I understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.(Required)III. CertificationI certify that all of the above information is correct to the best of my knowledge.(Required) I agree. Please note that once selected, your wages will be paid by the Monterey County Workforce Development Board. To that end, you will have to complete their paperwork and enrollment process. Please confirm that you understand.(Required) I understand. Do you have any of these documents? (Check all that apply)(Required) Birth Certificate Social Security Card Passport High School Transcript / Report Card State ID or Driver's License Right to Work Card None of the above Applicant's Signature(Required)Today's Date(Required) MM slash DD slash YYYY
