SHEBOYGAN AREA
YOUTH APPRENTICESHIP PROGRAM
2016 HEALTH APPLICATION
Have you discussed the commitment of an apprenticeship with your parents/guardians? Do you
understand that applying for an apprenticeship does not guarantee an interview? If hired, will you be
able to work before, during or after school? How about weekends, holidays and over the summer?
Most healthcare facilities require that ALL employees are available every other weekend to work. If
you’re interested in a Health- Nursing Assistant apprenticeship please be advised that successful
completion of the state certification in Nursing Assistant is required (approx. cost $115)
Every student interested in participating in Youth Apprenticeship will be required to complete
the application process. All applications must be TYPED. The application includes the
following:
I. Background Information and Time Commitment Forms
II. Parent or Guardian Information
III. Parent/Guardian Certification and Release Form
IV. Employment History
V. Applicant Program Interest Essay
VI. Attend Mandatory Nursing Assistant Forms & Fees Night on
Monday, April 4, 2016-5:30-6:30 p.m. at LTC Cleveland
THE LINK TO COMPLETE THE ELECTRONIC APPLICATION CAN BE FOUND AFTER
FEBRUARY 9, 2016 AT:
http://www.gotoltc.com/future-students/high-school/YA/apply/index.html
YOU MUST SUBMIT THE FOLLOWING DOCUMENTS WITH THIS APPLICATION
1. A copy of your high school transcript.
2. A copy of your high school attendance record for the current year.
3. Two recommendations are required. (One math or science teacher, one
counselor/teacher/advisor/coach) Please see forms for submission requirements.
4. For all CNA applicants- a verified job shadow is required for the interview process.
Fees- for Nursing Assistant ONLY- will be discussed further at a regional meeting
$16 Background Check Fee—check made out to: LTC
Complete TB Test
$115 (approx.) for State of Wisconsin Nursing Assistant Certification Test
Revised 1/22/2016
2016 HEALTH APPLICATION FORM
Sheboygan Area Youth Apprenticeship
HEALTH LEVEL-ONE
MISSION STATEMENT
The Wisconsin Health Youth Apprenticeship Program provides career preparation for high school students with
an interest in nursing. Participation in this program allows the student an opportunity to establish a strong
foundation in health care. Program requirements include work-based and educational components related to
the nursing field.
STUDENT NAME:
DATE:
HIGH SCHOOL:
HEALTH SCIENCE
Please indicate your choice of program (number 1 being highest preference-3 being lowest)
CERTIFIED NURSING ASSISTANT- SENIORS ONLY—
Must also complete the required Accuplacer Testing PRIOR to
MARCH 15, 2016. More information about the Accuplacer Testing can be
found on the yellow sheets within the provided information packet
DIETARY- JUNIORS OR SENIORS
MEDICAL OFFICE- JUNIORS & SENIORS (limited opportunities)
STUDENTS
RETURN COMPLETED APPLICATION AND DOCUMENTS
TO YOUR HIGH SCHOOL YOUTH APPRENTICESHIP LIAISON
BY February 26, 2016
LTC YOUTH APPRENTICESHIP COORDINATOR WILL PICK UP AT HIGH SCHOOL
DEADLINE: March 3, 2016
No individual shall be excluded from participation in, denied the benefits of, subjected to discrimination under, or denied employment in the administration
of or in connection with any Wisconsin Health Youth Apprenticeship Program on the basis of race, color, religion, sex, national origin, age, handicap,
political affiliation or belief, or sexual orientation.
Revised 1/22/2016
Sheboygan Area Youth Apprenticeship Application
WISCONSIN HEALTH ONE YEAR PROGRAM
I. BACKGROUND INFORMATION
Student Name
Address
City
Zip
Date of Birth
Phone
Cell Phone
High School
E-mail
Grade level for 2016-17 (check one)
Junior
Senior
Please list your high school activities, community service activities, honors received, and offices held.
Please list any courses, training or experiences you have completed that will enhance your
qualifications for the Wisconsin Health Youth Apprenticeship Program.
Please comment on your high school attendance record for the current year if any clarification is
needed.
Revised 1/22/2016
2
YOUTH APPRENTICESHIP TIME COMMITMENT
(June 2016 - May 2017)
I understand that a Youth Apprenticeship requires a time commitment beyond that of a typical high
school student. I will be asked to provide my work site with specific hours and days that I will be
available to work. I understand that timely communication with my work site mentor regarding
changes in my personal schedule is extremely important.
Below is a list of the other extracurricular activities (sports, musicals, band, vacations etc. in which I
currently plan to participate, as well as a summarized timeline for each activity. I am providing as
much information as I have available and being as specific as I possibly can at this time.
ACTIVITY PLANNED
GENERAL TIMEFRAME
(MONTHS)
Example: Football
August through November
EXPECTED TIME OF
DAY/HOURS
Practice M-Th from 3-7pm,
game every Friday
A Youth Apprentice must complete 450 total work hours during the year, which usually includes
summer work scheduling. This means that a typical Youth Apprentice dedicates an average of 10-12
hours per week to their job during the school year, and often more time during the summer.
As a Youth Apprentice, I agree to:
 Maintain the academic and attendance requirements enforced by the Youth Apprenticeship
Partnership, my school and my work site.
 Observe company and school rules and other requirements identified by the employer.
 Participate in progress reviews scheduled with mentors, school personnel and
parents/guardians.
 Understand that if I am hired by an employer, any requests I make to switch or transfer
places of employment will not be honored or fulfilled by the YA program unless warranted
and mutually agreed upon by all affected parties.

STUDENT SIGNATURE ________________________________ DATE ________________
PARENT SIGNATURE _________________________________ DATE ________________
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II. PARENT OR GUARDIAN INFORMATION
Father's Name
Daytime Phone
Mother's Name
Daytime Phone
Guardian's Name
Parent E-mail address
Daytime Phone
If parent address is different than student address, please list the parent address below.
Address
City
Zip
Phone
III. PARENT/GUARDIAN CERTIFICATION AND RELEASE
PRINT PAGE and then have Parent/guardian initial before each statement, student and
parent/guardian sign below.
____
I certify that the facts contained in this application are true and complete to the best of my knowledge
and understand that, if my student is selected for the Youth Apprenticeship Program, falsified
statements may be grounds for removal.
____
I certify that my student has a clean driving record and no felony convictions.
____
I understand that the student will be required to complete a background check and drug screening if
offered employment.
____
I authorize investigation of all statements contained herein and the references listed in this application
and all information concerning previous employers, and release all parties from liability for any
damage that may result from furnishing those to you.
____
I understand that LTC tuition fees required for related courses will be paid for through the Youth
Apprenticeship grant if my student earns a grade of C or higher, and if a grade below C level is
received, all costs will be the responsibility of my family.
____
I understand that the student must consult the high school liaison on payment for needed textbooks,
but it is the responsibility of the student to obtain necessary text book prior to the start of the LTC
class
____
I understand that a parent/guardian must attend, along with my student, any orientation session and
grading conferences that are required for the Youth Apprenticeship Program for which my child
wishes to apply.
____
I authorize the release of transcripts of grades and attendance records.
____
I understand that I am solely responsible for the transportation of the undersigned student to and/or
from the classroom or the work site and for all loss involved in said transportation.
____
I certify that the student has a valid driver’s license and adequate car insurance (necessary only in
those cases where the student will be driving to classroom or work site).
STUDENT SIGNATURE ________________________________ DATE ________________
PARENT SIGNATURE _________________________________ DATE ________________
Revised 1/22/2016
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IV. EMPLOYMENT HISTORY- please list previous employment:
1.
Employer's Name
Address
City/ZIP
Work Assignment
Dates of Employment
Phone
Supervisor
Student comments about work responsibilities and learning experiences:
2.
Employer's Name
Address
City/ZIP
Work Assignment
Dates of Employment
Phone
Supervisor
Student comments about work responsibilities and learning experiences:
Revised 1/22/2016
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V.
APPLICANT PROGRAM INTEREST ESSAY
IN A TYPEWRITTEN or WORD PROCESSED FORMAT, please explain why you feel you should be
selected for the Youth Apprenticeship Program. Do not exceed 250 words. Please include answers to
the following questions:
a) Why are you interested in the Youth Apprenticeship Program?
b) How do your career interests relate to the program area for which you are applying?
c) Why do you think you should be considered as an apprentice?
d) What is your long-term career goal?
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Revised 1/22/2016
Program Related High School Instructor
Recommendation Form—PRINT PAGE before completing
Return to High School Youth Apprenticeship Liaison in a sealed envelope
Student Name
Grade ____ High School _______________
This student is applying for the Wisconsin Health Youth Apprenticeship Program
Please refer to the checklist below to provide an accurate assessment of the applicant in the
following areas.
No Basis for
Judgement
Below
Average
Average
Above
Average
Excellent
(top 10%)
Academic Performance/Quality of Work
Responsibility
Attitude
Effort
Honesty
Dependability
Teamwork/Cooperation
Problem Solving
Leadership
Attendance
Please provide additional comments of the student's qualifications for this program.
____________________________________
PRINTED NAME OF REFERENCE PERSON
______________________________
POSITION/SUBJECT TAUGHT
____________________________________
SIGNATURE
________________________
DATE
Return to High School Youth Apprenticeship Liaison in a sealed envelope with your initials
signed on the seal by February 26, 2016 or e-mail to Jackie.holly@gotoltc.edu
7
Revised 1/22/2016
High School Personnel
Counselor, Club Advisor, Coach, Non-Program Teacher
Recommendation Form-PRINT PAGE before completing
Return to High School Youth Apprenticeship Liaison in a sealed envelope
Student Name
Grade ______ High School ______________
Please refer to the checklist below to provide an accurate assessment of the applicant in the
following areas.
No Basis for
Judgement
Below
Average
Average
Above
Average
Excellent
(top 10%)
Academic Performance/Quality of Work
Responsibility
Attitude
Effort
Honesty
Dependability
Teamwork/Cooperation
Problem Solving
Leadership
Attendance
Please provide additional comments of the student's qualifications for this program.
____________________________________
PRINTED NAME OF REFERENCE PERSON
______________________________
POSITION/SUBJECT TAUGHT
____________________________________
SIGNATURE
________________________
DATE
Return to High School Youth Apprenticeship Liaison in a sealed envelope with your initials
signed on the seal by February 26, 2016 or e-mail to Jackie.holly@gotoltc.edu.
Revised 1/22/2016
Wisconsin Health Youth Apprenticeship Program
Job Shadow Verification Form
FOR NURSING ASSISTANT ONLY
As part of the application process for the Wisconsin Health Youth Apprenticeship Program,
applicants must complete a job shadowing experience with a Certified Nursing Assistant (CNA).
Please contact Jackie Holly at 920.693.1128 or Jackie.holly@gotoltc.edu for assistance in this
process. This verification form must be completed and returned to Jackie Holly at LTC Cleveland,
1290 North Ave., Cleveland WI 53015 PRIOR to May, 2016 or your scheduled job interview date.
Applicant’s Name
High School_______________
Job Shadow Site____________________________________________________________
Address __________________________________________________________________
Job Shadowing Date _______________________________
Date _______________
A. To Be Completed by the CNA you are shadowing:
Name (printed) of CNA observed ______________________________________________________
Signature ________________________________________________________________________
Student Start and Finish Times ____________________________ Date _____________________
B. To Be Completed by the Applicant: (Attach separate paper with responses to 1-4).
(Hand-written answers on this form will not be accepted)
1. What are some of the responsibilities of a CNA (Certified Nursing Assistant)?
(Consider what you observed and discussed with the person you shadowed).
2. Why do you feel that working as a CNA will be a valuable learning experience? How do you see the CNA
role as a foundation for future health services careers?
3. What concerns do you have about becoming and working as a CNA? How will you handle these?
4. Were any of your career plans changed or reinforced by this experience? Explain.
Revised 1/22/2016
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