Complete this application accurately. The information provided here will be used by Community Kitchen staff to better understand each potential trainee's situation and needs. All information will remain confidential. Applications must include all documents (Police Report, Photo ID) and be properly filled out and completed.

    PERSONAL INFORMATION:

    First Name:

    Last Name:

    Gender:
    MaleFemaleOther

    DOB:

    Email Address:

    Phone Number:

    Current Address:

    City:

    Zipcode:

    SSN#:

    What is your racial background:

    If other, please specify:

    Are you a U.S. citizen?
    YesNo

    ELIGIBILITY REQUIREMENTS:

    All instruction for this program is conducted in English. Are you able to read, write and communicate in English proficiently?
    YesNo

    This program is 10 weeks long and requires attendance from 8:00AM- 3:00PM, Monday through Friday. Are you able to adhere to this schedule for the duration of the program?
    YesNo

    If no, please explain:

    Can you remain drug free and sober for the length of the 10 week training program?
    YesNo

    Are you currently low-income?
    YesNo

    Are you able to regularly perform required kitchen duties as assigned for a 7 hour day? Including but not limited to:
      • Standing at least four hours at a time without assistance
      • Ability to bend and lift a minimum of 50lbs

    YesNo

    INFORMATION ON HOUSEHOLD, TRANSPORTATION & LIVING SITUATION

    Housing Status:

    If in Transitional shelter, please specify where:

    Are you at risk of being homeless?
    YesNo

    If yes, please specify:

    Marital Status:

    Are you the head of your household?
    YesNo

    How many children:

    Ages of children:

    If yes, how do you plan to maintain stable childcare during the program?

    Primary means of transportation:

    If other, please specify:

    EMERGENCY CONTACT INFORMATION

    Name:

    Relationship to you:

    Phone Number:

    EDUCATION:

    Highest level of educational achievement:

    Other Special Training or Certifications:

    Do you have any prior food experience (e.g. employment, volunteer) or education?
    YesNo

    ADDITIONAL INFORMATION:

    How did you hear about the Cincinnati Cooks program?

    Please write a brief paragraph explaining why you are interested in this program:

    EMPLOYMENT HISTORY:
    (Note: Food experience is not a requirement for admission into the Cincinnati Cooks program).

    Employment Status
    Employed Full-timeEmployed Part-timeTemporary ServiceUnemployed

    Current Employer Information:

    Name of Supervisor:

    Supervisor's Phone#:

    Job Title:

    Duties/Responsibilities:

    Start Date:

    End Date:

    Reason for Leaving:

    MEDICAL HISTORY AND INFORMATION:

    Do you currently have a Primary Care Provider (i.e. doctor)?
    YesNo

    If yes, please indicate your doctor's name and phone number:

    Do you have any regular ongoing medical or behavioral health appointments?
    YesNo

    If yes, please explain:

    Do you have any medical conditions, handicaps, or impairments that make certain work or physical activities difficult for you?
    YesNo

    If yes, please explain:

    Are you currently taking any prescription medication?
    YesNo

    If yes, please list the names and schedule taken:

    Do you have any side effects, such as drowsiness, impaired motor skills, or impaired judgment when taking these medications?
    YesNo

    Are you currently or have ever been in any type of drug or alcohol rehabilitation program?
    YesNo

    Have you been diagnosed with Hepatitis A?
    YesNo

    SOCIAL SERVICES INFORMATION:

    Do you have a Case Worker/ Case Manager?
    YesNo

    Name:

    Agency:

    Phone#:

    Email:

    Do you currently have a source of income?
    YesNo

    Please select the source(s) of income you currently receive:
    EmploymentFamily SupportUnemploymentSocial SecuritySocial Security DisabilityOtherNone

    Other (Please explain):

    Are you currently receiving any of the following benefits or services?
    Food StampsMedicaid/AHCCCSCash AssistanceSSIUnemployment BenefitsOtherNone

    Other (Please explain):

    If yes, how long have you been receiving these benefits?

    Please specify the amount you receive:

    The staff at Freestore Foodbank wants to help all those who are enrolled in the program become as healthy, independent, and self-sufficient as they can be. In order to help you achieve your goals, both personal and professional, we would like to better understand what areas we could help you with while enrolled in our program. Please select any service(s) that we can help you with:

    Medical CareMental HealthSubstance Abuse TreatmentClothingDentalHealthDomestic Violence ServicesHousing/Utility ServicesFood Programs

    BACKGROUND INFORMATION

    Do you have a probation or parole officer?
    YesNo

    If yes, please indicate their name and phone#:

    Do you have any court cases or legal issues pending?
    YesNo</