Clinical Healthcare Career Pre-Apprenticeship Interest Form

First Name*

Middle Name

Last Name*

Chosen First Name

Preferred Pronouns

Select

Email Address*

Phone Number*

Phone

Mailing Address*

What is your highest level of education achieved?*

Select

What is your age?*

You must be a minimum of 17 years old to participate in this Pre-Apprentice program. If you are under 18 years old, we will send you information and a form for your parent/guardian to review and sign before you can begin the program.

If you are under 17 years old, please complete the form if you would be interested in learning about other opportunities at MaineHealth.

Select

Please enter your date of birth*

How many hours per week do you plan to spend on completing the pre-apprentice program?

This is a self-paced, online program where you can participate on a schedule that is convenient for you.

Select

Are you a current employee at MaineHealth?*

Yes

No

Do you have regular access to a computer (either laptop or desktop) with reliable internet access?*

Yes

No

Please share why you are interested in participating in the pre-apprentice program:*

Affirmative Action Questions

Completion of the following information is strictly voluntary. However, you must select 'I prefer not to answer' for each question if you choose not to provide us with that information.

As an Affirmative Action Employer, we are also collecting this information in connection with the Pre-Apprentice Program and request that you complete the information that applies to you. The information is confidential and will be used solely for statistical purposes. The information you provide, including if you choose 'I prefer not to answer', will not affect your being considered for participant and employment opportunities for which you are qualified.

Gender

Female

Male

Nonbinary

I prefer not to answer

Race

Hispanic or Latino

White (Not Hispanic or Latino)

Black or African American (Not Hispanic or Latino)

Native Hawaiian or other Pacific Islander (Not Hispanic or Latino)

Asian (Not Hispanic or Latino)

American Indian or Alaska Native (Not Hispanic or Latino)

Two or more races

I prefer not to answer

MaineHealth values diversity and is an Equal Opportunity/Affirmative Action employer. Federal and State laws prohibit discrimination in employment because of race, color, national origin, religion, age, sex, sexual orientation, disability, or veteran status.

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