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SEIU Healthcare 1199NW Multi-Employer Training Fund LifeTek Reimbursement Request Form

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Welcome to the SEIU Healthcare 1199NW Multi-Employer Training and Education Fund's LifeTek Reimbursement Form

Submit this quick form in order to notify your Training Fund that you are interested in having a LifeTek course paid for out of your Professional Development benefit. If you do not have enough funds to cover the full course cost you will be personally responsible for the remaining balance to LifeTek.

First Name

Last Name

Mailing Street Address

Mailing City

Mailing State

Mailing Zip Code

Preferred Phone Number

Mobile Phone

Work Phone

Home Phone

May we text you at this number in the future for updates on your benefits?

Preferred Email

Employer

Bargaining Unit

Job Title

Current FTE Range

Course Name You Want?

Date of Course

NOTE: PER DIEM, CONTRACT, AND REGISTERED NURSE EMPLOYEES ARE NOT ELIGIBLE FOR THIS SERVICE

Please Read Regarding Third Party Services:

The Training Fund contracts with vendors for provision of certain services. Based on the Trainings Fund’s contract with each vendor, the Training Fund has agreed that members accessing the service will comply with the policies and terms provided directly by the vendor. By utilizing vendor services though the Training Fund, members agree to these terms. If the vendor discontinues provision of service due to any reason for a member, Training Fund will work with member to explore alternatives that maybe available within current benefits, programs and services.

Amount

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• 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.

Contact Information