PRO TECH CONFERENCE TRAVEL & ATTENDANCE FUNDING AWARD REQUEST FORM

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Submit this form to request funding for conference travel and attendance (for our professional/technical members). Funding is awarded based on seniority and availability.

Not all expenses are eligible for reimbursement. For program guidelines, eligible and ineligible costs, and other details, please visit our website.

You must submit supporting documentation showing conference details to complete your application. This information needs to include details such as the start/end dates, the sponsoring organization, and proof that you will receive/obtain CEUs for your participation. If you need help uploading documents, please visit our Help with Online Tools page.

PLEASE NOTE: In order to be considered for an award you must submit your application BEFORE the conference. We cannot consider an award request for a conference that you have already attended. If you have already attended the conference it may be eligible for to be reimbursed up to $300 (pro-rated by your FTE) using your Professional Development reimbursement benefit. You can learn more about that here.

NOTE: PER DIEM & CONTRACT EMPLOYEES ARE NOT ELIGIBLE FOR THIS SERVICE

EMPLOYEE INFORMATION

First Name

Middle Initial

Last Name

Mailing Street

Mailing City

Mailing State

Mailing Zip/Postal

Preferred Phone Number

Mobile Phone

Work Phone

Home Phone

Primary Email

Email (please be sure you DO NOT share this email with another hospital worker such as a family/friend/co-worker/spouse/child - each person needs to have their own email and you can always use your work email if you don't have a personal email)

Employer

Worksite location

Note: Only Pro/Tech Bargaining unit members at the above employers qualify for this program!

Department

Job Title

Bargaining Unit

Current FTE

Date of Hire (mm/dd/yyyy format)

NOTE: PER DIEM & CONTRACT EMPLOYEES ARE NOT ELIGIBLE FOR THIS SERVICE

Conference Information

Conferences must award CEU's relevant to your current position in order to be considered for approval. You must submit documentation showing that the conference does award CEU's.

Conference start date

Conference end date

Will you be awarded CEU's for attending conference

Conference location (City and State)

Conference name

Conference sponsoring organization name

Registration Cost (no '$' needed just numbers. Ex. 220.25)

Lead Source

Record Type

Opportunity Name

Opportunity Stage

Your Manager's Approval is Required in order to process your request. Once we receive your request your manager will be sent an approval document.

Manager's First Name

Manager's Last Name

Manager's Title

Manager's Email

Manager's Phone Number

Contact Record Type

Required Supporting Documentation:

For the award process we only require a scanned or copied brochure for the conference or a screenshot of the conference's website showing the details and proof that you will obtain CEU's from the conference.

Pro/Tech Conference Award Backup Documents

Under penalty of perjury, I state that the information provided is correct. By signing this form, I approve the Training Fund to issue funding on my behalf.

Page 6

• https://healthcareerfund.org/wp-content/uploads/2018/08/Final-confidentiality-statement.pdf

• Please Note that in completing the attached "Application," you are also agreeing to the following statement:

I have had the opportunity to read and review the SEIU Healthcare 1199NW Training Fund Privacy Policy. By filling out and submitting this Application/Intake Form, I agree to this Privacy Policy and authorize the Training Fund to contact, or my behalf, current or previous employers or educational institutions, or other relevant entities, to obtain information that may be necessary for the administration of the Training Fund's benefits. I further understand this authorization is on-going for the purposes of administering the Training Fund's benefits.

I agree

DATA SHARING WITH LABOR MANAGEMENT PARTNERS

The SEIU Healthcare 1199NW Training Fund provides specific details about active members' usage of Training Fund programs and services to both employer and labor partners. Sharing this information allows labor/management partners to do more targeted workforce planning, and also support individuals in their career and programmatic path. Data that we share does not include Date of Birth and Social Security Number.

Do you agree to allow the Training Fund to share your information with employer partners:

Do you agree to allow the Training Fund to share your information with SEIU Healthcare 1199NW:

TEXT MESSAGING POLICY

Your education and career advancement and training opportunities are important to us. In order to provide you with the up-to-date-service, we occasionally send text messages to our members about their education and training benefits and services. Standard text messaging rates apply.

By completing this form, you authorize text messaging from Fund unless you decline text messaging. To decline Text Messages, email your Regional Education Navigator or members@healthcareerfund.org stating that you do not want to receive text messages.

You can decline text messages at any time. Under some circumstances this may delay your receiving information on your program(s). Please talk with your Navigator (if you don’t have one, one will be assigned on submittal of this form) if you have questions on text messaging.

PHOTO/VIDEO USE POLICY – TRAINING FUND EVENTS

The ability to communicate about Training Fund services to our members and to use information gathered in classes and sessions for further training is important to the Training Fund.

Unless you decline photo/video by the Fund, by completing this form you authorize and agree that the SEIU Healthcare 1199NW Multi-Employer Training & Education Fund and SEIU Healthcare 1199NW may use photographic images or video footage of you, or in which you are included, taken during Training Fund related classes, sessions, or events, for public relations, program marketing, electronic media, or educational purposes.

To opt out from photo/video use, please send a separate email your Regional Education Navigator or members@healthcareerfund.org stating that you do not want your images/video to be used for Training Fund purposes.

You may opt out of photo/video use at any time. Please talk with your Navigator (if you don’t have one, one will be assigned on submittal of this form) if you have questions on photo/video use.

NON-DISCRIMINATION POLICY STATEMENT

The Training Fund is dedicated to equal opportunity education and training. It does not discriminate on the basis of race, creed, color, ethnicity, national origin, religion, sex, sexual orientation, gender expression, age, physical or mental ability, veteran status, military obligations, background, or marital status.

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