Apply for Funded Healthcare Training | ATS Professional Development

1About you

First name *

Last name *

Preferred name

Pronouns

Date of birth

Phone *

Street address

Apartment or unit

City *

State

ZIP code *

Best days and times to reach you

Preferred way to reach youPhone callText messageEmail

2Eligibility and schedule

Are you 18 years of age or older? *

If you are under 18, please contact us before you submit and we will tell you what is possible.

YesNo

Can you attend every scheduled session for the full program? *Yes, the whole schedule works for meYes, but I will need to miss some sessionsI am not sure; I need help working it out

If you need help with the schedule, or already know about a conflict, describe it

A known conflict does not disqualify you.

How will you get to class?I have reliable transportationI will use SEPTAI need help with transportation

Do you have reliable access to a phone, a computer, and the internet?Yes, all threePhone onlyI need help with a device or internet access

3Education and work

Highest level of education you have completed *

School, program, or institution

City and state

Year completed or last attended

Your work situation right now *

Current or most recent job title

Employer

How long in that role

Have you worked in healthcare before, in any role?YesNo

If yes, where and what did you do?

Any role counts — dietary, housekeeping, transport, home care, front desk.

4Your certification interest

Pick a first choice. Second and third are optional, and we will talk you through what each job actually looks like before anything is decided.

First choice *

Second choice

Third choice

I am unsure and would like to talk through the options.

Why do you want a career in healthcare? *

Where do you want to be in one to three years?

Be as specific as you can — a job title, a wage, a shift that fits your life, a next credential.

5Professional development goals

If you chose Other, what would help you most?

What strengths, skills, or experience would you bring to this cohort?

Work, school, family, volunteering, caregiving, military — all of it counts.

Tell us about a time something got in your way and you kept going

Share only what you are comfortable sharing. This is read by program staff only, and there is no wrong answer.

6How you heard about us

How did you hear about us? *

Which organization, person, or place?

Optional, and it helps us thank the people who send us students.

7Support you may need

Answering yes to anything here does not count against you. It is how we plan ahead, and it is often the difference between finishing and dropping out.

Anything you want to add about the support you need

I would rather discuss my support needs privately. Please contact me.

Anything else you would like us to know?

8One reference

A supervisor, teacher, case manager, coach, pastor, or volunteer coordinator — not a relative. We contact them only if you check the box.

Reference name

Relationship to you

Phone number

Email address

I give ATS Professional Development permission to contact this reference about my application.

9Review and submit

Applying is not an acceptance, and cohort space is limited. If you are not selected for the next cohort we keep your application on file and consider you for future cohorts. If you are accepted, you will be asked to read and sign a Participant Agreement before classes begin — that is where the full program terms live.

The information in this application is accurate and complete to the best of my knowledge.I have read how ATS Professional Development uses the information on this form, and I received a copy of the Participant Privacy Notice.

The Notice opens in a new tab — your answers here are already saved. It explains what is shared with the funders who pay for the program, and what is not.

★Voluntary information — optional, and kept separate

This part is completely voluntary. Our funders require us to report who the program reaches, as totals only — we never report your name with these answers. Leaving it blank has no effect on your application, your selection, your cohort, or how you are treated in the program. These answers are stored apart from your application, and the staff who decide admissions do not see them.

Veteran or active military statusYesNoPrefer not to answer

Do you consider yourself a person with a disability?YesNoPrefer not to answer

Are you a resident of Philadelphia?YesNoPrefer not to answer