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: Hispanic/LatinoWhiteBlack/African AmericanAsianAmerican Indian/Alaskan NativeNative Hawaiian/Pacific IslanderOther Multi-racialOther
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: OwnRentStaying with family/friendHomelessTransitional shelterOther
If in Transitional shelter, please specify where:
Are you at risk of being homeless? YesNo
If yes, please specify:
Marital Status: SingleMarriedDivorcedDomestic Partnership
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: BusDriveWalkOther
EMERGENCY CONTACT INFORMATION
Name:
Relationship to you:
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
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
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
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:
