The Well CDC Akron -

Career Development Application Form

Thank you for your interest in our career development program. One of our first steps is a background check to identify jobs and career fields that best suit your eligibility. Please fill out the form below to authorize your background check and and identify your interests. If you have any questions, please email Morgan Villegas: morgan@thewellakron.com

First Name*

Last Name*

Preferred Pronouns?*

Social Security Number*

Date of Birth*

Preferred Method of Contact

Address Line 1*

Address Line 2

City*

State*

Zip Code*

Email*

Phone*

Gender

Ethnicity/Race

Primary Language?

Highest level of education

Are you currently enrolled in school?

Yes

No

Are you enrolled in the Summit County Public Health | Healthy Moms, Healthy Babies Program?*

Yes

No

Is childcare a major barrier for you?

Yes

No

Is transportation a major barrier for you?

Yes

No

What are you looking for in a job/career?*

Are you willing to commit to our 5 week program, Tuesday through Friday from 10AM-2PM, to help you establish the next steps in your career search?

Yes

No

How did you hear about The Well CDC Career Development Program?*

Have you ever been convicted of a misdemeanor or felony (this does not disqualify you)? If yes, please explain.*

Authorization for Background Check

I hereby certify that the information provided is complete and accurate to the best of my knowledge. I also authorize The Well CDC and/or its representatives to verify income, employment; and conduct credit and background checks.

Please type your full name and today's date below for authorization.