Found in Translation - Program Application

advertisement
Found in Translation - Program Application
Completed applications should be mailed to:
Found in Translation
P.O. Box 560052
Medford, MA 02155
If you have any questions, please contact Maria Vertkin at [email protected]
Are you a woman?
⟰ Yes
⟰ No
(ineligible for this program)
Are you eligible to work in the United States?
⟰ Yes
⟰ No
(ineligible for this program)
Are you fluent in English and another language?
⟰ Yes
⟰ No
⟰ Not sure
(ineligible for this program)
Contact Information
Name: _____________________________
Address: ______________________________
Phone: _____________________________
______________________________
Email: _____________________________
______________________________
Languages
My first language is _________________________
How well do you speak in this language? _________________________
How well do you read and write in this language? _________________________
My second language is ______________________
How well do you speak in this language? _________________________
How well do you read and write in that language? _________________________
Add any other languages you can speak, read, or write:
Language: _________________________
Language: _________________________
Language: _________________________
Language: _________________________
⟰ Speak
⟰ Speak
⟰ Speak
⟰ Speak
⟰ Read
⟰ Read
⟰ Read
⟰ Read
⟰Write
⟰Write
⟰Write
⟰Write
Availability
Daytime
Evening
⟰ Mon
⟰ Mon
⟰ Tue
⟰ Tue
⟰Wed
⟰Wed
⟰ Thur
⟰ Thur
⟰ Fri
⟰ Fri
⟰ Sat
⟰ Sat
⟰ Sun
⟰ Sun
Questions 1-7 are about your income and housing status. These questions must be
answered completely in order for you to be considered for this program.
1. How many people are in your household, including yourself? _______
Please provide the following information for all household members, including yourself:
Name:
Age:
Relationship to you:
Employed?
____________________________ ____
_________Self__________ ⟰ Yes ⟰ No
____________________________ ____
______________________ ⟰ Yes ⟰ No
____________________________ ____
______________________ ⟰ Yes ⟰ No
____________________________ ____
______________________ ⟰ Yes ⟰ No
____________________________ ____
______________________ ⟰ Yes ⟰ No
____________________________ ____
______________________ ⟰ Yes ⟰ No
____________________________ ____
______________________ ⟰ Yes ⟰ No
____________________________ ____
______________________ ⟰ Yes ⟰ No
2. Income in the last 30 days:
3.
Earned income
$_______
Unemployment Insurance
$_______
SSI
$_______
Disability Insurance
$_______
SSDI
$_______
Alimony or Child Support
$_______
TANF
$_______
Gifts
$_______
Retirement income
$_______
Other: ________________
$_______
What is your typical total household income (usually)?
$_________/month
***Note: You will be asked to show evidence of your total household income
(for example: pay stubs, employment verification, or tax returns)
4. Non-cash benefits you currently receive:
⟰ Food Stamps/SNAP
⟰WIC
⟰ SCHIP
⟰ Veteran Services
⟰ TANF Transportation
⟰ TANF Childcare
⟰ Other TANF Services
⟰ Medicaid (MassHealth)
⟰ Medicare
⟰ Section-8
⟰ Rental Assistance
⟰ Fuel Assistance
⟰ Other: ______________________
⟰ Public Housing
5. Have you experienced homelessness?
⟰ Yes, currently
⟰ Yes, in the past
⟰ Never
6. What is your current housing situation?
⟰ Emergency Shelter
⟰ Transitional Housing
⟰ Permanent Housing
⟰ Hotel or Motel
⟰ Staying/living with Family ⟰ Staying/living with friend(s)
⟰ Rental with subsidy
⟰ Rental, no subsidy
⟰ Own a home
⟰ Other: ______________________________________
⟰ Section-8 or Public Housing
7. Describe any financial hardships you are experiencing:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Questions 8-11 are about your educational and professional development. These
questions help us to understand your individual learning needs so that we can provide
you with the right tools and supports for you to succeed.
8. What is your highest level of education completed?
⟰ No formal education
⟰ 1st-8th grade
⟰ Some high school
⟰ High School or GED
⟰ Some College
⟰ Associate’s Degree
⟰ Bachelor’s Degree
⟰ Master’s Degree
⟰ Doctorate or PhD
⟰ Certificate: __________________________
⟰ Other: _____________________
9. What kind of a learner are you (your learning style, strengths, and difficulties/challenges)?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
10. Do you have a resume? ⟰ Yes ⟰ No
11. Please provide the following information for all current and past employment, including paid
positions, internships, and volunteer positions:
Employer: ___________________________
Position: _______________________________
Duties/responsibilities: ___________________________________________________________
Hours/week: _____
Wages/Salary: $____________ Start date: ___/___ End Date: ___/___
What did you like most about this position? __________________________________________
What was most difficult about this position? __________________________________________
Why did you leave this job? _______________________________________________________
Employer: ___________________________
Position: _______________________________
Duties/responsibilities: ___________________________________________________________
Hours/week: _____
Wages/Salary: $____________ Start date: ___/___ End Date: ___/___
What did you like most about this position? __________________________________________
What was most difficult about this position? __________________________________________
Why did you leave this job? _______________________________________________________
Employer: ___________________________
Position: _______________________________
Duties/responsibilities: ___________________________________________________________
Hours/week: _____
Wages/Salary: $____________ Start date: ___/___ End Date: ___/___
What did you like most about this position? __________________________________________
What was most difficult about this position? __________________________________________
Why did you leave this job? _______________________________________________________
Employer: ___________________________
Position: _______________________________
Duties/responsibilities: ___________________________________________________________
Hours/week: _____
Wages/Salary: $____________ Start date: ___/___ End Date: ___/___
What did you like most about this position? __________________________________________
What was most difficult about this position? __________________________________________
Why did you leave this job? _______________________________________________________
Employer: ___________________________
Position: _______________________________
Duties/responsibilities: ___________________________________________________________
Hours/week: _____
Wages/Salary: $____________ Start date: ___/___ End Date: ___/___
What did you like most about this position? __________________________________________
What was most difficult about this position? __________________________________________
Why did you leave this job? _______________________________________________________
Starting a new career is never easy, and the Found in Translation training program is
intense and a very serious commitment. Questions 12-15 are your opportunity to show
to us that are ready to take on this enormous challenge.
12. Why do you want to become a medical interpreter? What motivates you?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
13. Why do you think you will be a good medical interpreter? What strengths and personal
qualities do you think you can bring into this profession?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
14. Tell us about a time when you decided to do something big in your life and succeeded in
getting it done. How did you achieve success?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
15. Tell us about a time when you did not succeed. Looking back, was there something you
could have done differently?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
I certify that the information I have provided in this application is true to the best of my knowledge.
Signature: ______________________________
Thank you for applying!
Download