Please complete this application accurately and legibly. The information provided here will be used by Freestore Foodbank staff to better understand each potential trainee's situation and needs. All information will remain confidential.

    PERSONAL INFORMATION:

    Name:

    MaleFemaleOther

    DOB:

    Email Address:

    Phone Number:

    Current Address:

    City:

    Zipcode:

    SSN#:

    Are you a U.S. citizen?
    YesNo

    INFORMATION ON HOUSEHOLD, TRANSPORTATION & LIVING SITUATION

    Specify current housing status:
    OwnRentStaying with friend/familyTransitional shelterHomelessOther

    If in homeless or transitional shelter, please specify where:

    Current relationship status:
    SingleMarriedDomestic PartnershipDivorced

    Are you the head of your household?
    YesNo

    How many children:

    Ages of children:

    Do the children reside in the household?
    YesNo

    ELIGIBILITY REQUIREMENTS:

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

    Are you able to regularly perform required warehouse duties as assigned for a 8 hour day? Including but not limited to:
      • Standing for long periods of time
      • Ability to bend and lift a minimum of 50lbs
      • Able to drive and operate powered equipment safely

    YesNo

    The program is 10 weeks long and requires attendance from 9am-3pm, Monday-Thursday and 9am-12pm 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

    ADDITIONAL INFORMATION:

    How did you hear about the LIFT the TriState program?
    Gateway CollegeCustomer Connection Center, Freestore FoodbankFacebookFriend/FamilyBelflexOther

    Other:

    Why are you interested in this program? (2-3 sentences):

    EMERGENCY CONTACT INFORMATION

    Name:

    Relationship to you:

    Phone Number:

    EMPLOYMENT/VOLUNTEER HISTORY:
    (Please provide complete information on your last three jobs, starting with the most recent. Note: Warehouse experience is not a requirement for admission into the LIFT the TriState program).

    Employer (Company Name):

    Name of Supervisor:

    Supervisor's Phone#:

    Job Title:

    Duties/Responsibilities:

    Start Date:

    End Date:

    Reason for Leaving:

    EDUCATION:

    Highest level of educational achievement:

    Other special training or certifications:

    SOCIAL SERVICE INCOME INFORMATION:

    Do you have a Case Worker/ Case Manger?
    YesNo

    Name:

    Agency:

    Phone#:

    Email:

    Do you currently have a source of income?
    YesNo

    Are you currently low-income?
    YesNo

    Are you currently unemployed?
    YesNo

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

    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?

    If yes, Please specify the amount you receive for each benefit:

    Employment Amount:

    Unemployment Amount:

    Food Stamps Amount:

    Social Security Amount:

    Social Security Disability Amount:

    Cash Assistance Amount:

    Other (please list benefit and amount):

    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. Please select any areas that you need assistance with:

    Medical CareMental HealthSubstance Abuse TreatmentClothingDentalHealthDomestic Violence ServicesHousing/Utility ServicesFood Programs

    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

    Have you been diagnosed with HIV or AIDS?
    YesNo

    BACKGROUND INFORMATION

    Do you have a probation or parole officer?
    YesNo

    If yes, please indicate their name and phone number:

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

    If yes, please describe and provide date:

    Please list criminal convictions below:

    Describe Conviction:

    FelonyMisdemeanorNo Convictions

    Date:

    County or Location:

    -------------

    Describe Conviction:

    Felony