Cincinnati Cooks Application

Media•on August 24th, 2015•Comments Off on Cincinnati Cooks Application

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 for long periods of time
  • 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).

Are you currently unemployed?
Employed Full-timeEmployed Part-timeTemporary Service

Employer (Company Name):

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 Manger?
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

If yes, please describe and provide date:

PLEASE SEND ALL REQUIRED DOCUMENTS TO:

Rosenthal Community Kitchen:
Cincinnati COOKS!
1141 Central Parkway
Cincinnati, Ohio 45202

Please call 513-482-7298 with questions.

DISCLAIMER AND SIGNATURE:

I certify that my answers are true and complete to the best of my knowledge. If this application leads to enrollment in the program, I understand that false or misleading information in my application or during my interview may result in my release from the program. If this application leads to enrollment in the program, I understand that I may be asked to take and pass a physical exam, drug and alcohol screening, have a TB test done, and/or have a doctor's release to participate.

Signature: (type your full name)

Date: