MedCertify Skills 2 Succeed Eligibility Form
All answers are confidential and used to determine eligibility status for tuition assistance. This form is HIPPA compliant and secure.
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
What is your age?
Are you interested in job search and resume preparation assistance?
*
Yes
No
Are you interested in a paid work experience?
*
Yes
No
Are you interested in employability workshops?
*
Yes
No
Are you interested in taking the WorkKeys test?
*
Yes
No
Are you currently working?
*
Yes
No
Do you receive public assistance? (TANF, KTAP, SSI, SNAP)
*
Yes
No
Are you a high school dropout and earning a GED?
*
Yes
No
Are you pregnant or parenting?
*
Yes
No
Do you have a disability?
*
Yes
No
Are you homeless? (No permanent residence)
*
Yes
No
Are you over the age of 55?
*
Yes
No
Have you been unemployed for 12 consecutive weeks or more?
*
Yes
No
Have you been unemployed for 14 of the last 27 weeks?
*
Yes
No
Do you have a sporadic work history, including a history of temporary/seasonal employment, multiple terminations, or multiple quits?
*
Yes
No
Do you lack a work history? (i.e. Have not had a job)
*
Yes
No
Are you drawing unemployment?
*
Yes
No
Are you a displaced homemaker? (i.e. Have you been providing unpaid services to family members in the home and been dependent on the income of another family member but no longer supported by that income (due to divorce, spouse laid off, spouse filed for disability)
*
Yes
No
Are you the spouse of a member of the Armed Forces on active duty and who has experienced a loss of employment as a direct result of relocation to accommodate a permanent change in duty station?
*
Yes
No
Have you had a misdemeanor or felony?
*
Yes
No
What is your approximate income in the past six months?
*
Submit
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