Worker Retraining Program Intake Form

Worker Retraining Program Intake Form
The Business Resource Center of South Clackamas County has partnered with Clackamas Community College (CCC) and is offering qualified students scholarships per quarter, to cover the cost for allowable CCC Career & Technical Education programming for Winter 2024 & Spring 2025. This program will be available until all funds have been allocated.

These scholarship awards are available to students residing in the following zip codes* and are listed in the CCC registration system: Gladstone (97027), Oregon City (97045), Beavercreek (97004), Canby (97013), Molalla (97038), Mulino (97042), Estacada (97023), Eagle Creek (97022), and Colton (97017). *This is the service area of the Business Resource Center of South Clackamas County.

Eligible costs include but are not limited to tuition, fees, books, other costs directly associated with the program. Please fill out the following form below to be considered for this scholarship. Once a student’s CTE registration is complete and their Work Re:Training Program application is approved each scholarship will be processed on a first come, first served basis. We look forward to helping you elevate your future in 2024-2025!
Applicant Name*

First NameLast Name
Cell Phone Number*
Please enter a valid phone number.
Student ID #*
Current Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of CTE Program*
CCC Term:
Are you fully enrolled at CCC for the next term?*

Fully EnrolledNot yet or Partially
FINANCIAL QUALIFICATIONS SECTION

Instructions: Applicants may qualify for this program through one (or more) of three financial qualifications (Financial Qualifications Section) and through signature on both attestations, below. Select at least one option from the Financial Qualifications Section. You only have to qualify in ONE option to be eligible.

OPTION 1: Are you enrolled in any of the following public assistance programs?
Check all that apply, if any:*

Children's Health Insurance Premium (CHIP)Childcare subsidies through the Child Care and Development Fund (CCDF) ProgramMedicaidNational Housing Trust Fund (HTF), for affordable housing programs only(HOME), for affordable housing programs onlyTemporary Assistance for Needy Families (TANF)Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)Supplemental Nutrition Assistance ProgramFree and Reduced-Price Lunch (NSLP) and/or School Breakfast (SBP) programsLow-Income Home Energy Assistance ProgramMedicare Part D Low-Income SubsidiesPell GrantsHead Start and/or Early Head StartSection 8Supplemental Security Income (SSI)Does Not Apply to Me
OREGON CITY CHAMBER COMPLETION ONLY:
Does the applicant meet financial eligibility standards for Option 1 using the material submitted?

YesNoDifferent Option Used
Documentation used for determination
Option 2: Income qualifications

If you did not qualify for Option 1, above, please provide either your most current tax return OR your most recently completed FAFSA when you return this form. We will use your documentation to determine if you meet income eligibility thresholds to qualify under Option 2. If you do not have either of these documents, please contact us to arrange for submission of potentially different documents.
OREGON CITY CHAMBER COMPLETION ONLY:
Does the applicant meet financial eligibility standards for Option 2 using the forms submitted?

YesNoDifferent Option Used
Documentation used for determination
FPGAMI
REQUIRED ATTACHMENTS for Scholarship Verification & Qualification:

1. Copy of current/up-to-date CCC Student I.D.

2. Government Issued I.D.

3. Proof of Zip Code (Examples Include: Utility Bill or CCC Registration)
Note: Provide a document for one option, not both.

OPTION 4 ATTACHMENT: Refer to the boxes selected in Option 1, provide a statement or approval/renewal letter from one of the agencies providing the assistance. The statement or letter should be issued within the last two months or should show a period of eligibility which covers the date you are signing this scholarship application form.

OR

OPTION 5 ATTACHMENT: Provide your most recently filed tax return OR your most recently filed FAFSA when you return your application. The Business Resource Center of South Clackamas County will use the income figures in the document you return to verify your eligibility via your income level.
ATTACH REQUESTED DOCUMENTS HERE:

PDF format perfered but JPG and PNG files accepted.
Upload File
ATTESTATION SECTION (REQUIRED)

By my signature below, I attest that at least one of the following is true of me:
1. I am currently employed but am seeking to move to a job that provides better opportunities for economic advancement, such as higher wages or more opportunities for career advancement.
2. I am unemployed but want and am available for work.
3. I have looked for work sometime in the past 12 months.
4. I am employed part time but want and am able for full-time work.
SIGNATURE OF APPLICANT:
I further attest by my signature, below, that all of the information provided herein is true to the best of my knowledge and that I may be subject to criminal prosecution for any false or misleading information used to receive benefits under this grant-funded program.*

Clear
Email Address of Applicant*
example@example.com
Date Signed*

MonthDayYear
Date
DAS Contract 8223
Should be Empty:

Worker Retraining Program Intake Form

FINANCIAL QUALIFICATIONS SECTION

OPTION 1: Are you enrolled in any of the following public assistance programs?

OREGON CITY CHAMBER COMPLETION ONLY:

Option 2: Income qualifications

OREGON CITY CHAMBER COMPLETION ONLY:

REQUIRED ATTACHMENTS for Scholarship Verification & Qualification:

Note: Provide a document for one option, not both.

ATTACH REQUESTED DOCUMENTS HERE:

ATTESTATION SECTION (REQUIRED)

SIGNATURE OF APPLICANT:

DAS Contract 8223