Healthcare Support Occupations Application
NOTE: All communication regarding selection will be exclusively through your email address. Please check your junk/spam folder.
Today's Date
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Month
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E-mail
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example@example.com
Name
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First Name
Last Name
Gender
Male
Female
Birth Date Must be 18 years old on or before March 9, 2026
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Month
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Year
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Age
Home Number
Cell Number
Street Address
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City & State Name
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Zip Code
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What is your birth country?
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Do you have a valid California ID or California Driver's License?
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What is your home language?
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What is your primary language?
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Health Information (Optional)
Please let us know about any medical conditions, physical limitations, or other health considerations that may be relevant (e.g., allergies, chronic conditions, mobility restrictions, pregnancy, medication needs, etc.). This information will be kept confidential and added to your student profile in the case of any emergency. If applicable, please list any relevant health information below (optional):
If applicable, please list any relevant health information below (optional):
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Emergency Contact
Please provide the first and last name of your emergency contact.
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Emergency contact's relationship to applicant
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Please provide the contact number for the above Emergency Contact.
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Please enter a valid phone number.
Education
Have you earned your high school diploma or GED?
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Yes
No
Please enter the year you graduated from high school or the year you joined your GED.
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In which city did you graduate or earn your GED?
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In which state did you graduate or earn your GED?
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Please provide the name of the school you earned your high school diploma or GED.
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Highest Education Earned
High School
Associates
Bachelors
Masters
Doctorate
Career Technical Education/ Certification
Other
Are you currently enrolled in any educational programs, schools, classes, or colleges? If yes, please explain.
Have you previously graduated from a BAS Health Careers Program(s)?
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If applicable, please list any health industry certifications you currently possess or any experience in the health industry.
Computer Skills
How would you rate your computer skill level?
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Never used a computer
Beginner
Competent
Highly Proficient
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Employment Information
Are you currently employed?
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Yes
No
Where are you currently employed?
What is your current position/job title?
If you are currently employed, what is the name of your supervisor?
Please provide the contact number of your supervisor. (###) ###-#### (If not applicable, enter N/A)
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Professional Reference
If not applicable, please type N/A
Professional Reference Full Name
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Title/Position
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Phone
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Professional Reference Full Name
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Title/Position
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Phone
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Professional Reference Full Name
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Title/Position
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Phone
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Background
All applicants must pass a background check with no convictions (felony/misdemeanor) and no pending charges. Please note: If a background check is flagged for any reason, we can not proceed with enrollment.
Do you have any prior convictions or pending charges?
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Yes
No
If yes, please explain briefly:
Drug Testing
If selected for a BAS Health Careers program, drug testing will be required. A positive drug test will prevent you from being accepted into our health careers programs and/or being removed from the programs.
I understand that I will not be accepted and/or will be removed from any BAS Health Careers program if I receive positive drug test results.
Yes, I understand.
Payment Deadlines
If selected for a BAS Health Careers program, I am committed and prepared to meet the payment deadlines in this program.
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Yes, I am.
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Short Response Questions
A large part of the selection process is based on the quality of your responses in this section. Please take your time and respond using complete sentences, punctuation, proper spelling and grammar. (Minimum of 3-5 sentences per response)
The medical field offers a wide variety of jobs. What specific job might you be interested in? (3-5sentences)
What has inspired you to pursue an education in health careers? (3-5 sentences)
Are you looking for immediate employment in the healthcare industry or will you be continuingyour health careers education? (3-5 sentences)
In your own words, describe your definition of quality customer service and patient care? (3-5sentences)
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I hereby certify that all the statements made hereon are true and correct to the best of my knowledge. I understand that any false statements on this application will be cause for dismissal from the training program. I further understand that all background information will be verified via fingerprinting, both federal and DOJ background check.
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Please type your first and last name.
Please enter today's date.
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Disclaimer
The Kern High School District (KHSD) is committed to ensuring equal, fair, and meaningful access to employment and education services. KHSD prohibits discrimination, harassment (including sexual harassment), intimidation, or bullying in any employment practice, education program, or educational activity on the basis and/or association with a person or group with one or more of these actual or perceived characteristics of age, ancestry, color, ethnic group identification, gender, gender identity or expression, genetic information, immigration status, marital status, medical information, national origin, physical or mental disability, parental status, political affiliation, pregnancy and related conditions, race, religion, retaliation, sex, sexual orientation, military or veterans status, homelessness, foster status, affiliation with the Boy Scouts of America and other designated youth groups, or any other basis prohibited by California state and federal nondiscrimination laws consistent with Education Code 200 and 220, Government Code 11135, and Title IX. If you believe you have been subjected to discrimination, harassment (including sexual harassment), intimidation, or bullying you should contact your school site principal and/or the District's Equity Compliance/Title IX Officer, Melissa Jimenez, 5801 Sundale Avenue, (661) 827-3173, titleix@kernhigh.org, Title II/ADA Officer, SELPA Director Special Education, Greg Hicks 5801 Sundale Avenue, (661) 827-3105, greg_hicks@kernhigh.org, and Section 504 Coordinator, Elaine Gregory, 5801 Sundale Avenue, (661) 827-3288, elaine_gregory@kernhigh.org. A copy of KHSD's Uniform Complaint policy and Nondiscrimination policy are available at www.kernhigh.org and upon request..
I have read the Disclaimer above
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Yes
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Signature:
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