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The employment and training programs offered at Middlesex (Middlesex Community College)

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The employment and training programs offered at Middlesex Community College (MxCC)
provide SNAP recipients with career pathway training, mentoring, and support services to
prepare them for job opportunities in health-related careers and more. MxCC is pleased to offer
SNAP Recipients access to federally-funded scholarships, which are administered through the
department of social services (DSS), to attend one career training program.
The goal of the program is to help students gain skills and training that may lead to employment
and financial independence. After students successfully complete the program, they will be
awarded an official program certificate, which also has the potential to open doors for future
educational and career training opportunities.
If you are receiving SNAP in Connecticut and are not receiving money from the Temporary
Family Assistance (TFA) program, you may be eligible to participate in SNAP E&T. E&T is a
skills-based career pathway training program that provides short-term, vocational training as a
foundation on a career pathway. Programs include: Certified Nurse Aide, Phlebotomy
Technician, Security Guard, Patient Care Technician, Pharmacy Technician, Veterinary
Assistant, Human Services Assistant, Central Sterile Processing Technician, and Medical Billing
and Coding.
Enclosed are the following documents needed to be considered for an employment and
training program:
I. Participant Expectation and Commitment Form
II. A copy of a Photo ID and EBT card
III. SNAP E&T Application
IV. FFERPA Release Form
V. Non-Credit Registration Form
VI. MxCC Student Registration Form
VII. Health Form (Depending upon clinical program requirements)
Applications should be submitted to: Julie Roebelen, M.Ed. at: JRoebelen@mxcc.edu
There is no deadline for application submission. Applications will be accepted and reviewed as
they are submitted. Incomplete applications will not be accepted.
For more information about the CTPathways Program, please visit: https://mxcc.edu/ce/snap/
PARTICIPANT EXPECTATIONS and COMMITMENT
Participant Name: _________________________________ DSS CL#:_____________________________
SNAP employment and training is a work program that is intended to help support you in achieving
your educational and career goals. Please read and sign the Student Expectations and Commitment
form and the Authorization to Release Education Records form in order to participate in the SNAP
employment and Training (E&T) program.
I understand that the SNAP E&T is an employment programs and the intent is to help me get the
skills I need to get a job. I am committed to completing my educational plan, earning a certificate or
degree, and getting a job. I am aware that there are resources available to assist me in my job
search and the SNAP coordinator will guide me through the process. I must be able and available to
work upon completion of the program.
My SNAP E&T coordinator is Julie Roebelen. I can reach the coordinator by email at
jroebelen@mxcc.edu or by phone at 860-343-5736.
I understand that SNAP E&T is a program offered by Department of Social Services (DSS)
and that in order to participate in SNAP E&T I must be receiving SNAP from DSS.
Participation in SNAP E&T will not affect my direct SNAP nutrition assistance and I may
receive SAGA cash assistance. I understand that I cannot receive TFA cash assistance and
participate in SNAP E&T.
I understand that participation in SNAP E&T is generally limited to one program per
participant. I will inform the SNAP coordinator if I have participated in any other SNAP
funded education program in the past.
I understand that the SNAP coordinator will confirm my eligibility every month that I
receive services and that I must submit all required paperwork and information to DSS to
maintain SNAP benefits. I will communicate with the SNAP coordinator if there are any
changes and I will immediately notify the coordinator of any changes to my address, phone
number or email address.
E&T participants may receive reimbursement for expenses that are reasonably necessary
and directly related to participation in the E&T program. Allowable expenses for identified
needs will be reimbursed upon presentation of appropriate documentation to the E&T
service provider.
My success in the program is my responsibility and depends on my commitment to attend
classes regularly and participate in class lessons, discussion and any other activities that are
assigned.
I understand that if I am not able to fulfill the above expectations, I may lose my SNAP E&T
eligibility.
My signature below confirms that I understand all of the above expectations and I am committed to
the SNAP E&T program.
_________________________ _______________ _______________________ ____________
Participant Signature Date Coordinator Signature Date
The Connecticut Department of Social Services
APPLICANT INFORMATION
Name:
Date:
Date of Birth:
DSS Client #:
Street Address:
City:
Phone: cell
home
Email:
SNAP Household Size:
# of Adults:
# of Children:
Gender: Male
Female
Race:
American Indian
Alaska Native
Asian
Black or African American Native
Hawaiian/Pacific Islander
White
Other
Unknown
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Unknown
Language:
EDUCATION INFORMATION
Do you have a high school diploma or GED? Yes No
What is your highest level of education?
List all colleges you have attended.
How did you hear about the program?
FINANCIAL INFORMATION
Receiving SNAP? Yes No
Receiving TFA? Yes No
Receiving Social Security? Yes No
Are you currently employed? Yes No PT FT
Are you currently receiving unemployment? Yes No
EMPLOYMENT HISTORY
Employer Name:___________________________________ Position Title:____________________________________________
City, State:__________________________________________ Hours per week:________________________________________
Start Date:__________________________________________ End Date:_________________________________________________
Employer Name:__________________________________ Position Title:___________________________________________
City, State:_________________________________________ Hours per week:________________________________________
Start Date:__________________________________________ End Date:_________________________________________________
Employer Name:__________________________________ Position Title:____________________________________________
City, State:_________________________________________ Hours per week:________________________________________
Start Date:_________________________________________ End Date:__________________________________________________
Employer Name:__________________________________ Position Title:_______________________________________
City, State:_________________________________________ Hours per week:____________________________________
Start Date:_________________________________________ End Date:____________________________________________
Please provide three references: (community or employment
Name:________________________________ Relation:____________________________ Phone #:____________________
Name:________________________________ Relation:____________________________ Phone #:____________________
Name:________________________________ Relation:____________________________ Phone #:____________________
Program(s) I'm Interested in:
□ Central Sterile Processing
□ CNA
□ Human Services
□ Medical Billing & Coding
□ PCT
□ Phlebotomy Tech.
□ Pharmacy Tech.
□ Security Guard
□ Veterinary Assistant
The Connecticut Department of Social Services
Goals:
Why do you want to participate in the program:
Please list some of your strengths, skills, abilities and/or interests that will help you reach
your career goals.
1.____________________________________________________________________________________________________________________
2.____________________________________________________________________________________________________________________
3.____________________________________________________________________________________________________________________
4.____________________________________________________________________________________________________________________
5.____________________________________________________________________________________________________________________
6.____________________________________________________________________________________________________________________
What have your previous experiences in school been like? (check all that apply)
❑ Rewarding ❑ Encouraging ❑ Frustrating
❑ Fun ❑ Challenging ❑ Discouraging
❑ Exciting ❑ Easy ❑ Difficult
What are some potential obstacles and challenges that you may encounter in
pursuing your career goals? (i.e. transportation, childcare, disability, etc.)
Student Signature:____________________________________ Date:_________________________________________________
Staff Signature:________________________________________ Date:_________________________________________________
This institution is an equal opportunity provider.
Authorization to Release Education Records Form for SNAP E&T Program
Participants
As required, I will complete my Free Application for Federal Student Aid (FAFSA) every
year by the deadline established by the E&T coordinator, with the understating that if my
income or unmet need changes, it is possible that I will no longer qualify for tuition
assistance through SNAP E&T. I understand that I must achieve Satisfactory Academic
Progress (SAP) as defined by financial aid (more information on this definition at
www.fafsa.org).
As a participant in the SNAP E&T program I understand that my SNAP coordinator is
required to communicate my academic progress and participation on a monthly or as
needed basis to the Department of Social Services (DSS). Further I understand that because
of the affiliation of SNAP E&T with DSS, DSS must have access to my educational and
financial aid information. Therefore, I hereby consent to and authorize the release of
pertinent educational and financial information to DSS when and as needed for my
participation in the SNAP E&T program.
I have been informed and understand that my education records are protected from
disclosure under the Family Educational Rights and Privacy Act, but that I may consent to
disclosure and authorize release of my education records to third parties.
__________________________ ____________________
Signature Date
__________________________ ____________________
Coordinator Signature Date
Middlesex Community College
Non-Credit Program
Supplemental Application
PLEASE PRINT CLEARLY USING BLUE OR BLACK INK
Apt #
State Zip Code
Cell Phone
Birth date
Full Name
Street Address
City
Home Phone
Email
Emergency Contact Contact’s Phone
Do you consider yourself to be Hispanic/Latino? Yes No
What is your race? (select one or more) White Black or African American Asian
American Indian or Alaska Native Native Hawaiian or Other Pacific Islander
Are you a U.S. Citizen? Yes No If no, are you a permanent resident? Yes No
Have you ever taken a credit or non-credit course at one of the CT Community Colleges? Yes No
Are you a current MXCC student? Yes No
Are you planning to utilize a payment plan for this program? (for programs over $1,000) Yes No
Are you receiving third party funding? Yes No If yes, what is the funding source?
Is English your second language? Yes___ No___If yes, have you taken an ESL test? Yes____No_____
An ESL test is recommended prior to enrolling if English is your second language. Call 860-343-5770 to schedule.
Education
High School Graduate: Yes____No____ Currently attending_____ GED Certification: Yes____No____
Name of High School: ________________________________ Year of Graduation:
College:
Are you a Nurse Aide whose certification has expired? Yes____ No____ If yes, registration #______________
I certify that the information provided above is, to the best of my knowledge, true and correct, and I consent to
the disclosure of this and program participation information between Middlesex Community College,
Connecticut State Colleges and Universities and state and federal Departments of Labor for the purposes of
maintaining accurate student records and to monitor grant performance.
Signature:
Program:
Banner ID: Date:
Completed applications should be submitted along with all required materials to:
Middlesex Community College
Office of Enrollment Services
100 Training Hill Road
Middletown, CT 06457
Rev. 6/2017
✔
SNAP
CREDIT CARD#
CRN# DEPT & COURSE # COURSE TITLE
# OF
CREDITS
TIME
FROM – TO
DAYS
ROOM
M T W R F S
M T W R F S
M T W R F S
M T W R F S
M T W R F S
M T W R F S
M T W R F S
M T W R F S
The student meets the prerequisites required for the above course(s) by presenting
ACT/
AP/SAT Scores,
Placement Scores, or
Unofficial Transcript.
Please list CRNs: ____________________________________________________________________ Advisor Initials: _______________
Once this registration is processed, you are responsible for the charges associated with registration. Detailed information about this
and other College Policies can be found in the MxCC College Catalog on our website. It is the responsibility of each student to read the
policies of Middlesex Community College. The student’s signature on this form is acknowledgement of receipt of this statement and
acceptance of the terms and conditions of all policies.
TODAY'S DATE
ADVISOR'S SIGNATURE
TOTAL CREDITS
STUDENT'S SIGNATURE
REGISTRATION FORM
MxCC REV
03/20
MIDDLESEX COMMUNITY COLLEGE
STATE OF CONNECTICUT
OFFICE USE ONLY
DO NOT WRITE IN THIS SPACE
CPE
Employee Waiver
High School Partnership
Non-Credit
Platt High School Seat
Senior Citizen
Veteran:
31
33
1606
DD214
EXPIRATION DATE &
CVV
#
SIGNATURE
DISTRIBUTION:
White – Enrollment Services Office Pink - Business Office
STUDENT ID:
@
THIS REGISTRATION IS FOR:
□
FALL
□
SPRING
□
SUMMER
□
INTERSESSION
YEAR ___________
NAME: LAST FIRST MAIDEN NAME OR MIDDLE INITIAL
ADDRESS (NO. AND STREET)
□
PLEASE CHECK HERE IF CHANGE OF ADDRESS
CITY/TOWN
STATE
ZIP CODE
PHONE: HOME
PHONE: CELL
EMAIL ADDRESS
□
PLEASE CHECK HERE IF CHANGE OF EMAIL ADDRESS
DATE OF BIRTH
/ /
GENDER
□
MALE
□ FEMALE
US VETERAN
□
YES
□ NO
STUDENT STATUS:
□ NEW
□ CONTINUING
□ READMIT
SEMESTER LAST ATTENDED: □
FALL
□
SPRING
□
SUMMER
□
INTERSESSION
Y
EAR ____________
N/C 3rd Party Funding Source: ________________
If you're emailing this form, do not include credit card number.
If it’s required, you'll be contacted.
Middlesex Community College
Non-credit Allied Health Programs
HEALTH FORM
Please circle program
CNA
PCT
Phlebotomy Technician
This form must be completed and signed by your Health Care Provider.
Return form to MxCC Continuing Education Office.
Questions: Contact Marge Valentin at (860)343-5716
Veterinary Assistant
or email mvalentin@mxcc.edu
Name
Address
Date of Birth
Phone number
On (date)_________________I examined this student and found him/her to be in good health. He/she is free
of any communicable disease, can lift 50 pounds and has no known deficits that would interfere with the ability
to participate in a clinical setting.
Pregnant: Yes No (please circle)
Healthcare Provider STAMP
Signature:
Phone number:
Comments:
IMMUNIZATIONS - Required for all CNA, PCT and Phlebotomy Technician Students
Veterinary Assistant students do not need to submit immunization information
1
MMR (one must be given after 1980)
DATE RESULT
MMR #1
MMR #2
2
Rubella Screening
Rubella serum test for immunity
Rubella immunization
3
Measles Screening
Measles serum test for immunity
Measles immunization
4 Mumps Screening
Mumps serum test for immunity
Mumps immunization
5 Varicella (Chicken Pox) History
Varicella Vaccine #1
Varicella Vaccine #2
Varicella antibody test
History of disease
6
Tetanus vaccine (must be given within last 10 years)
7 Hepatitis B Vaccine series #1 #2 #3
Hep B test for immunity
8 Seasonal Influenza Vaccine (Required Spring & Fall semesters)
See page 2 for Tuberculosis Screening, Hepatitis B Waiver and Medical Insurance Certification. Rev.03/2016
CSPT
Middlesex Community College HEALTH FORM page 2
Non-Credit Allied Health Programs
Student Name
ANNUAL TUBERCULOSIS SCREENING
Students in the CNA program are required to have a One Step Tuberculosis Skin Test.
Students in the PCT and Phlebotomy Technician programs must have a Two Step Skin Test.
Tuberculosis screening must be done within 12 months of admission to the program.
Previous BCG Vaccine does not exempt student from tuberculosis screening.
A QuantiFERON blood test is an acceptable alternative to skin testing
Date Results Date/Signature
TB Skin Test #1
TB Skin Test #2
(Phlebotomy students only)
or
TB Blood Test (QFT-G)
Chest x-ray
(if above testing is positive)
HEPATITS B WAIVER
Hepatitis B vaccination is optional. You should discuss this option with your primary care provider and
either begin the vaccination series or sign the waiver below.
I waive Hepatitis B vaccination at this time.
Student Signature Date
MEDICAL INSURANCE
Medical Insurance is required for all students.
I certify that I carry a current Medical Insurance Policy
Student Signature Date
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Completed 8 February 2021

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