CELACare Work/Life Application

Please include all requested information for each of the work/life experiences you list on the application below

CELACare Online Application for Work/Life Credit :

Subject(required)

Name(required)

Student ID #

Email(required)

Telephone

Address (complete address)(required)

WORK/LIFE EXPERIENCE #1 - Include in your response the following information: (1) type of service, (2) name of agency, (3) address where service provided, (4) start and ending dates of services, (5) total hours completed for each date range(required)

Description of activity for work/life experience #1(required)

Preparation: briefly list and describe the steps that were required of you prior to beginning this project. What did you do to prepare to undertake your project? (Do not list the steps of the project itself) for work/life experience #1(required)

Reflection: what did you accomplish or learn from this service and learning experience? How did this experience impact your life and the lives of others?--for work/life experience #1(required)

Certification: what area of CELACare Eco-Health Home Health Aide Certificate Program or Eco-Health Care Certificate Program requirements does this experience meet?--Work/life experience #1(required)

Reference: All work/life experience service and learning activities will be verified by CELA. Please provide the following information for work/life experience #1(required)

Name of reference(required)

Position/Title of reference(required)

Agency/Organization of reference(required)

Agency or organization address of reference(required)

WORK/LIFE EXPERIENCE #2 - Include in your response the following information: (1) type of service, (2) name of agency, (3) address where service provided, (4) start and ending dates of services, (5) total hours completed for each date range

Description of activity for work/life experience #2

Reflection: what did you accomplish or learn from this service and learning experience? How did this experience impact your life and the lives of others?--for work/life experience #2

Certification: what area of CELACare Eco-Health Home Health Aide Certificate Program or Eco-Health Care Certificate Program requirements does this experience meet?--Work/life experience #2

Reference: All work/life experience service and learning activities will be verified by CELA. Please provide the following information for work/life experience #2

Name of reference

Position/Title of reference

Agency/Organization of reference

Agency or organization address of reference

WORK/LIFE EXPERIENCE #3 - Include in your response the following information: (1) type of service, (2) name of agency, (3) address where service provided, (4) start and ending dates of services, (5) total hours completed for each date range

Description of activity for work/life experience #3

Reflection: what did you accomplish or learn from this service and learning experience? How did this experience impact your life and the lives of others?--for work/life experience #3

Certification: what area of CELACare Eco-Health Home Health Aide Certificate Program or Eco-Health Care Certificate Program requirements does this experience meet?--Work/life experience #3

Reference: All work/life experience service and learning activities will be verified by CELA. Please provide the following information for work/life experience #3

Name of reference

Position/Title of reference

Agency/Organization of reference

Agency or organization address of reference

WORK/LIFE EXPERIENCE #4 - Include in your response the following information: (1) type of service, (2) name of agency, (3) address where service provided, (4) start and ending dates of services, (5) total hours completed for each date range

Description of activity for work/life experience #4

Reflection: what did you accomplish or learn from this service and learning experience? How did this experience impact your life and the lives of others?--for work/life experience #4

Certification: what area of CELACare Eco-Health Home Health Aide Certificate Program or Eco-Health Care Certificate Program requirements does this experience meet?--Work/life experience #4

Reference: All work/life experience service and learning activities will be verified by CELA. Please provide the following information for work/life experience #4

Name of reference

Position/Title of reference

Agency/Organization of reference

Agency or organization address of reference

BY CHECKING THIS BOX I CONFIRM (1) that all the information contained in this application, including any supplemental information and documentation, is factual, true, and honestly presented; (2) that I am the person submitting the application; (3) that I understand that incomplete applications cannot be processed by CELA; (4) that an incomplete application is one where the application signature and date are missing and/or supporting supplemental information, documents, materials have not been submitted.(required)

PLEASE TYPE YOUR FULL NAME, YOUR INITIALS, AND THE DATE IN THE TEXT BOX BELOW TO COMPLETE THE APPLICATION:(required)

Applications submitted without the full information, especially contact information, that is requested for each work/life experience listed will be considered incomplete. Incomplete applications cannot be processed.