SEP App Portage 2017-11-20T15:44:57+00:00

CAP Services’ Skills Enhancement Program Screening/Application Form

Individuals must be working at least 20 hrs/week and have a household income at or below 150% of the federal poverty guidelines. When you complete the form and click “send”, it will automatically be emailed to the Skills Development Manager in your county for review. If you qualify, an application will be sent to you to be completed.

Fields marked with asterisk (*) are required.

Personal Information

Name
Your Name (Last, First, M.I.)*

Address
Street Address* (Apt # if applicable)

City*

State*

ZIP Code*

County*

Mailing Address (if different from above)
Street Address (Apt # if applicable):

City

State

ZIP Code

Contact
Home Phone*

Alternate Phone

Email Address

Re-type Email Address

Birth Date*

Gender*
MaleFemale

Marital Status

PLEASE EXPECT A CALL OR EMAIL FROM A SKILLS DEVELOPMENT MANAGER WITHIN ONE WEEK OF SUBMITTING FORM

Best way to contact you?*
PhoneEmail

If you qualify, a program application must be filled out.
Would you prefer the application to be mailed or emailed?*
MailedEmailed

Income Information

Title

Hours per week*

Employer

Is health insurance available to you through your employer?

Monthly cost of insurance

Wages (per hour)*

How many people live in your household?*

How many dependents do you support?*

Does spouse have earned income?

Spouse's income

The following should be considered income: Wages/salary before deductions, Net receipts from self employment, Social Security, Workers Compensation, Alimony, Military Allotments, SSI/SSDI, Unemployment Compensation, Work Study

Income that would not be counted includes: Child Support (income paid out in child support can be deducted), Higher Education Grants/Scholarships, Tax refunds, Gifts, Non-cash benefits such as Food Share, housing assistance, etc., Job Corps payments

County Services

Please check any county services you receive:
Food ShareMedical AssistanceBadger CareWICChild Care AssistanceOther

Points of Interest

What part of the Skills Enhancement Program is of interest to you? (Check all that apply)
Assistance with transportation to/from schoolAssistance with childcare while taking classesEducational costs for tuition, books, and fees

What is your education/training/career goal?

Are you currently enrolled in an education/training program?

If so, where?

How long will it take you to achieve this goal?

Have you applied for financial aid?

Are you aware of job opportunities in area?

Are you willing to relocate for a job?

Without the support of this program, would you be able to achieve you job advancement goals?

If yes, how?

If no, what other resources have you explored to assist with this goal?

How did you hear about the Skills Enhancement Program at CAP Services, Inc?