* Application must be completed in entirety to be accepted. (In addition to this application, official ID and high school diploma/GED will need to be submitted prior to acceptance in the program) Personal Information Name
Secondary and Postsecondary Education
Complete education history.
(If more than four children, please list name age, and school/daycare/Head Start or caregiver information in the "Additional Information” section at the end of the application.)
Child 1 -Stays home with you or family caregiver? Child 1 - In Public School? Child 1 In a Head Start Class? Child 1 - In Daycare ? Child 2 Child 2 - Stays home with you or family caregiver? Child 2 - In Public School? Child 2 - In a Head Start Class? Child 2 - In Daycare? Child 3 Child 3 - Stays home with you or family caregiver? Child 3 - In Public School? Child 3 - In a Head Start Class? Child 3 - In Daycare? Child 4 Child 4 - Stays home with you or family caregiver? Child 4 - In Public School Child 4 - In a Head Start Class? Child 4 - - In Daycare? Employment History If you are awarded a scholarship, do you have transportation? Have you been laid off over the past 12 months due to no cause of your own? If not working now, why? Explain Employment Status Do you plan to seek employment in sterile processing if selected for the program? Felony/Drug History Conviction(s) Have you ever been convicted of or pled no contest or guilty to any felony or any serious crime? Please answer the following three questions. Why do you want to complete the Sterile Processing program and begin a career in the field? How will this opportunity help your family? Why should you be selected for this program? Would you be comfortable working in a non-patient health care position with the main responsibility being sterilization and infection control? Do you have basic computer skills? Do you have a home computer or laptop? Would you agree to report your employment status for one year? Would you agree to attend all classes, workshops, study labs and individual career counseling appointments (some appointments may be outside of class times)? Are you up to date on immunizations?
(TB Skin Test, MMR (two are required within lifetime), Varicella, Hepatitis B, Flu, Tetanus)
Are you able to complete a clinical rotation at an outside health care facility?
(Hours will be different than the scheduled class.)
Use the space below to provide any additional information about yourself that you would like to share with us.
This can be personal, academic, or professional. (If you have more than four children, provide the names, ages, school,/daycare./Head Start/ or caregiver information here)
Scholarship Application Submission Agreement By typing your name in the signature box below you agree to the following statement: I represent and warrant that the information I have given on this application is full and true to the best of my knowledge and belief. I further acknowledge that I understand that I may be asked to provide documented verification of education, experience, and required certifications and/or licensures. And further, I represent and warrant that I have answered fully and truthfully all questions regarding criminal convictions/records. I have read and understand the details of the Women’s Foundation Sterile Processing Tech Grant Scholarship Class. I understand that participation in this program may include a criminal background check and drug screen. I understand that I may be required to travel to different locations for class, labs, clinical rotations, workshops, study labs, career appointments or to use the computer lab during times outside of class time. I understand that classes will require extended time and effort outside of class to successfully complete the program. I agree that, once I complete the program I will seek employment as a sterile processing technician, take the national certification exam and establish a career in the field. Student Grade Release Form By typing your name in the signature box below you agree to the following statement: I understand that The Women’s Foundation of Alabama is sponsoring this Career Scholarship Program and as such, I am giving permission for Jefferson State Community College to release any information to that organization related to class attendance, conduct, academic honesty and grades. In addition, I am also giving Jefferson State Community College’s One Stop Career Center permission to release information about my participation in any of their services. Student Photo Release Form By typing your name in the signature box below you agree to the following statement: I do hereby release all rights or claims in connection with the photo(s) or video in which I appear, for use by Jefferson State Community College or partner grant agencies. I understand that the photo(s) or video, if used, will be used for the promotional purpose of assisting Jefferson State Community College and grant partners and I waive any claim to financial remuneration for the use of these photo(s) or video. I also waive any right to inspect or approve the finished photos and advertising copy.
I hereby release Jefferson State Community College, its legal representatives and all persons acting under its permission or authority, from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in taking of said picture(s) or video or in any subsequent processing thereof, as well as any publication thereof.
I declare that I am of legal age and have every right to contract in my own name in the above regard.