YOUR APPRENTICESHIP
Victor Valley College - VVC
Healthcare - Registered Nurse
APPRENTICE INFORMATION
Referring agency:
Orientation date: July 6, 2023
Victor Valley College Nursing Department
LEAVE BLANK IF NOT APPLICABLE
Apprentice full name: Maritza Diaz
Apprentice email:
XXX-XX-XXXX 9 digits
Date of birth: 07-21-1987
Cal Jobs #: N/A
LEAVE BLANK IF NOT APPLICABLE
DD-MM-YYYY
FIRST, MIDDLE AND LAST NAME
Phone #: (951) 327-3556
diazm97205@student.vvc.edu
Mobile?
(XXX) XXX-XXXX
Apprentice address:
e
Stat : CA
14534 Owl Ct
Are you over 18?
N
Y
Minors, please provide name of Parent or Guardian:
Y
N
Highest education completed: 4 or More Years of College
Ethnicity:
N
Homeless Status: Select Option
Select Option
OPTIONAL
LEAVE BLANK IF NOT APPLICABLE
Gender Identity: Female
Gender: Female
SELECT FROM DROP-DOWN MENU - DO NOT LEAVE BLANK
Foster Youth:
Y
Do you consider yourself disabled:
N
LEAVE BLANK IF NOT APPLICABLE
Email and Phone # of Parent or Guardian:
Are you
e
e
a V t ran?
Y
Zip code: 92394
PLEASE PROVIDE A PHYSICAL ADDRESS. DO NOT PROVIDE P.O. BOX ADDRESS.
Sexual Orientation: Select Option
OPTIONAL
OPTIONAL
Race: White
HISPANIC - A person of Mexican, Puerto Rican, Cuban, Central American, South American, or other Spanish culture or origin, regardless of race.
SELECT FROM DROP-DOWN MENU - DO NOT LEAVE BLANK
SELECT FROM DROP-DOWN MENU - DO NOT LEAVE BLANK
Y
Do you have the right or are legally authorized to work in the U.S.?
Dependents: 3
N
DO NOT COUNT YOURSELF
Number of years you have been employed full time to date (except for military service): 5 Years or More
Are you currently employed?
Y
N
If employed:
Employer Name:
1
2
SELECT FROM DROP-DOWN MENU - DO NOT LEAVE BLANK
PART TIME
FULL TIME
Are you employed in the program industry?
Current wage:
LEAVE BLANK IF NOT APPLICABLE
ORIENTATION - STEPS
Apprentice SS#: 614038444
0263661
During my apprenticeship, my educational goal is
to complete/obtain: An Apprenticeship Certificate & College Degree
REGISTER FOR RELATED-EDUCATION COURSES To be completed by apprenticeship coordinator.
Enroll:
Full-time
First Apprenticeship Term Year:
Part-time
08/2023
TERM/YYYY
Course Code & Title: NURS 220/246
Enrollment in Term:
Spring
Summer
Fall
Winter
Course Code & Title: NURS 221
Enrollment in Term:
Spring
Summer
Fall
Winter
Course Code & Title: NURS 222/223
Enrollment in Term:
Spring
Summer
Fall
Winter
Course Code & Title: NURSE 224
Enrollment in Term:
Spring
Summer
Fall
Winter
3
START ON THE JOB LEARNING
To be completed by apprenticeship coordinator.
Based on the job readiness requirements of the program, your on the job-learning projected start is:
09/2025
MONTH/YEAR
Depending on the program, job readiness for this apprenticeship will include:
✔
✔
Completing required course(s)
Passing program technical assessment
Obtaining a faculty referral
LAUNCH ORIENTATION FORM - UPDATE VERSION 2023.4
✔
N
PER HOUR, IF EMPLOYED
APPLY TO THE COLLEGE
If you already have a Student ID, please enter it here:
Y
Preparing/updating your resume
Preparing for an interview
Reviewing available job description with program staff
Other: PASSING VVC Nursing Program/
NCLEX
YOUR APPRENTICESHIP
(from page 1)
Victor Valley College - VVC
Healthcare - Registered Nurse
Apprentice full name (will populate from page 1): Maritza Diaz
4
APPRENTICESHIP AGREEMENT
To be reviewed and signed by the apprentice. The parent or guardian must also sign the agreement if the apprentice is a minor.
By signing this form, I will initiate my status as an apprentice in the program and:
1.
ORIENTATION - STEPS
2.
3.
All apprentices must complete a 3-month probationary period, during which time any violation of the rules and regulations below, or
failure to complete job readiness assignments will result in automatic cancellation of this apprentice agreement.
I will enroll and actively engage in the courses and training applicable to my apprenticeship pathway.
If not employed as an apprentice with an affiliated company, I will actively pursue employment by communicating with program
staff and following all pre-employment procedures as directed.
4.
I will adhere to the employer's hiring standards and employment practices of the employer(s) that provide on-the-job learning
during my apprenticeship.
5.
I will communicate ANY changes impacting my participation and progress to the program staff in a timely basis. This includes but is
not limited to:
•
•
•
Changes to my personal contact information.
Changes impacting my ability to complete the apprenticeship.
Changes regarding my employment status.
6.
I will review and respond to communication sent by mail, or electronically by apprenticeship program staff to the contact
information provided at the top of the orientation form.
7.
I will join and utilize Work Hands, the online on-the-job learning tool the program uses to track my progress in the program.
8.
I understand that my participation in the apprenticeship program is voluntary. By signing below, I authorize the release of
information relative to my participation in this program to required third parties as determined by apprenticeship program staff. The
principle purpose for collecting this information is to administer the program, including tracking and evaluating participant progress.
I also authorize the release of any information relative to my placement, employment, and training to and from prospective
employers, training institutions, state agencies, and federal agencies for the duration of my participation in the apprenticeship
program. All information provided is for the sole use of apprenticeship program and will be maintained securely and confidentially.
Failure to promptly complete, sign, and return this orientation form will delay your registration as an apprentice and all applicable tuition and
enrollment fees will be charged to your student account.
Apprentice Signature:
Date:
Parent/Guardian Signature:
Date:
Coordinator Signature:
Date:
For coordinator use only
Don't register with DAS until after this date:
ELECTRONIC SIGNATURE AGREEMENT (If applicable)
By completing this transaction electronically, you acknowledge that you have read, understand and agree that:
•
•
This transaction is being conducted by electronic means in accordance with the federal Electronic Signatures in Global and National Commerce Act (E-Sign), 15 U.S.C.A. Sections 7001-7031 and the
Uniform Electronic Transactions Act, California Civil Code sections 1633.1 to 1633.17;
Completion of this transaction electronically shall have the same effect as if you signed your name in ink on a piece of paper to accomplish the transaction, and LAUNCH Apprenticeship Network
will store by electronic means an electronic record of this transaction.
LAUNCH ORIENTATION FORM - UPDATE VERSION 2023.4