Bursary Program Intake Form - Choose2Care.ca

HCA Bursary Program Intake Form

The Choose2Care team supports Health Care Assistants (HCA) at different stages of their registration with the BC Care Aide and Community Health Worker Registry (the Registry) to meet the increasing demand of HCA staff in BC.

The Choose2Care team would like to contact you to discuss your eligibility to participate in a bursary program to provide you with financial assistance for expenses associated with your registration process (such as HCA competency assessment, remedial education). If you are interested in participating in the bursary program, please fill out the information below so that a Choose2Care team member may contact you directly.

HCA Bursary Program Intake Form

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Personal Information:

Name

First

Middle

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Acknowledgement & Consent:

Please read the following and check the boxes below to finalize and submit your intake.

A&C_1

As indicated by my agreement below, I confirm that the contents of this intake are true and complete to the best of my knowledge and belief.

A&C_2

I understand that all personal information related to my intake form for the Choose2Care Bursary Program is collected in accordance with the applicable privacy legislation, for the purposes of administering my participation in the program, facilitating the evaluation process, funding verification, entitlement, disbursement of financial stipends, grants, reimbursement or waiver programs, statistical analytics, surveys, research, potential recruitment, employment, and other such related purposes. I understand that no personally identifiable information will be disclosed to outside parties, except as described in this intake form.

A&C_3

I consent to my personal information being shared both by and with the BC Care Aide & Community Health Worker Registry and Inspire Global Assessments/Inspire Évaluations Mondiales (previously the Nursing Community Assessment Service (NCAS)) for the purposes of; processing my bursary application, determining eligibility and entitlement for this bursary reimbursement program, funding verification, facilitating the evaluation process, and any other such related purposes.

Signature

Type your full name

Date of signature

A&C_4

I attest that my typed name in the signature line above is equivalent to my legal signature.

If you have any questions about the application form or the use of this information, please contact us at info@choose2care.ca

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