Fillable PERSONAL CARE AIDE (PCA)/ HOME HEALTH AIDE (HHA)/ (Capital Region BOCES)

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PERSONAL CARE AIDE (PCA)/ HOME HEALTH AIDE (HHA)/ (Capital Region BOCES)

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  • 26 check-boxes
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Country of origin: US
File type: PDF

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Please print or type all information.
Applying for: (
check all that apply)
Home Health Aide (HHA)
Personal Care Associate (PCA)
Nurse Assistant (NA)
Albany Campus Schoharie Campus
Day
Evening
Starting Date___________________________
Name:
Last
First
MI
PERSONAL CARE AIDE (PCA)/
HOME HEALTH AIDE (HHA)/ NURSE ASSISTANT
(NA) APPLICATION
Address:
Street
City State
Zip
Date of Birth:
Age: Social Security # Sex: [ ] Female [ ] Male
Telephone: ( )
Cell: ( ) E-Mail:
PERSONAL STATUS: (Check one) [ ] Veteran [ ] U.S. Citizen or [ ] Alien Registration #
(copy of card required)
FAMILY STATUS: (Check one) [ ] Single [ ] Married [ ] Widowed [ ] Separated [ ] Divorced
Write in each box, the number of your own children by age group who are living with you.
[ ] 0-2 [ ] 3-5 [ ] 6-12 [ ] 13-16 [ ] 17+
EDUCATION/TRAINING: Highest grade of school completed: _______ Grad. date: ________ GED date:__________
How did you learn about this program? ________________________________________________________________
[ ] Referral Source: ____________________________ Phone number _________________________
Are you presently employed? [ ] No [ ] Yes
If yes, Employer: __________________________________ Job Title: ___________________________
Are you receiving unemployment? [ ] No [ ] Yes
Do you receive any of the following Public Assistance? (Check all that apply):
[ ] Rental Assistance from the Department of Social Services
[ ] Aid for Dependent Children (AFDC)
[ ] Supplemental Security Income (SSI)
[ ] Women, Infants and Children (WIC)
[ ] Home Relief (HR) [ ] Medicaid
[ ] Food Stamps
Do you have a disability or medical condition that may affect or limit your ability to work or attend school?
[ ] Yes [ ] No If "yes," please describe ____________________________________________________________________
NOTE:
Any previous criminal felony or misdemeanor conviction may prevent you from obtaining Certification.
PLEASE NOTE:
All information on this form is CONFIDENTIAL. Only the data will be used for statistical purposes.
SIGNATURE: DATE:
PERSONAL CARE AIDE (PCA)/
HOME HEALTH AIDE (HHA)/ NURSE ASSISTANT (NA)
APPLICATION
Please write a statement explaining what you hope to gain by coming to BOCES at this time:
Release of Information:
I understand that the information on this application will be kept private and confidential. I allow
Albany-Schoharie-Schenectady-Saratoga BOCES to submit this application to appropriate
funding agencies to ascertain my eligibility for financial assistance to attend BOCES Adult
Education Programs. I allow BOCES to use this release of information to seek and provide
information to relevant agencies within and outside BOCES and to employers regarding my
attendance and participation as based on funding assistance requirements. I understand that
information regarding current status of physical, medical and psychological conditions will be
sought and secured by a separate release outlining the need and use of information requested.
Signature: Date:
Staff Signature: Date:
CONSENT FORM
[ ] I give consent (agree)
[ ] I do not give consent (do not agree)
to allow the release of information (data from this application, test data, notes,
correspondence and other documents) in written or verbal to personnel from the referring
agency and/or other relevant funding agencies and appropriate organizations.
Signature: Date:
Witness Signature/Title: Date:
PERSONAL CARE AIDE (PCA) /
HOME HEALTH AIDE (HHA)/NURSE ASSISTANT (NA)
EMPLOYMENT HISTORY
Please list all employment in the last five years (list most recent experience first).
1. Employer: From: To:
Addres
s: T
itle:
Job Responsibilities
:
2.
E
mploy
er: From: T
o:
Address: Title:
Job Responsibilities
:
R
eason for Leaving:
3. Employer: From: To:
Addres
s: T
itle:
Job Responsibilities
:
R
eason for Leaving:
SIGNATURE: DATE:
If you need the assistance of an interpreter, need material translated into any language other than English, please call Ottavio Lo Piccolo at (518)
862-4703 and leave a voice message. Thank you. Si usted necesita asistencia de un interprete, o necesita traducion en espanol, y otros idiomas, por
favor llame a Ottavio Lo Piccolo a este tel. (518) 862-4703, y deje un mensaje de voz. Gracias
The Capital Region BOCES does not discriminate on the basis of race, color, national origin, sex, disability, or age in its programs, activities,
employment, and admissions; and provides equal access to the Boy Scouts and other designated youth groups. The following person has been
designated to handle inquiries regarding the non-discrimination policies: Robert Zordan, compliance
officer/coordinator, at
robert.zordan@neric.org, (518) 862-4910 or 900 Watervliet-Shaker Road, Albany, NY 12205. Inquiries concerning the
application of the Capital Region BOCES nondiscrimination policies may also be referred to the U.S. Department of Education, Office for Civil Rights
(OCR), 32 Old Slip,26th Floor, New York, NY 10005, telephone (646) 428-3800 (voice) or (800) 877-8339 (TTY).
ALBANY | SCHOHARIE | SCHENECTADY | SARATOGA | Board of Cooperative Educational Services
Career & Technical School – Adult Health Careers
1015 Watervliet-Shaker Road, Albany, NY 12205 • (518) 862-4709 • www.capitalregionboces.org/careertech
An Equal Opportunity Employer
accessible 1/18
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PERSONAL CARE AIDE (PCA) HOME HEALTH AIDE (HHA) (Capital Region BOCES)

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Completed 16 September 2021

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