LIFT ApplicationPlease 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:MaleFemaleOtherDOB:Email Address:Phone Number:Current Address:City:Zipcode:SSN#:Are you a U.S. citizen?YesNoINFORMATION ON HOUSEHOLD, TRANSPORTATION & LIVING SITUATIONSpecify current housing status:OwnRentStaying with friend/familyTransitional shelterHomelessOtherIf in homeless or transitional shelter, please specify where:Current relationship status:SingleMarriedDomestic PartnershipDivorcedAre you the head of your household?YesNoHow many children:Ages of children:Do the children reside in the household?YesNoELIGIBILITY REQUIREMENTS:All instruction and testing for this program is conducted in English. Are you able to read, write and communicate in English proficiently?YesNoAre 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 safelyYesNoThe 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?YesNoIf no, please explain:Can you remain drug free and sober for the length of the 10 week training programYesNoADDITIONAL INFORMATION:How did you hear about the LIFT the TriState program?Gateway CollegeCustomer Connection Center, Freestore FoodbankFacebookFriend/FamilyBelflexOtherOther:Why are you interested in this program? (2-3 sentences):EMERGENCY CONTACT INFORMATIONName: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?YesNoName:Agency:Phone#:Email:Do you currently have a source of income?YesNoAre you currently low-income?YesNoAre you currently unemployed?YesNoPlease select the source(s) of income you currently receive:EmploymentFamily SupportUnemploymentSocial SecuritySocial Security DisabilityOtherOther (Please explain):Are you currently receiving any of the following benefits or services?Food StampsMedicaid/AHCCCSCash AssistanceSSIUnemployment BenefitsOtherNoneOther (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 ProgramsMEDICAL HISTORY AND INFORMATION:Do you currently have a Primary Care Provider (i.e. doctor)?YesNoIf yes, please indicate your doctor's name and phone number:Do you have any regular ongoing medical or behavioral health appointments?YesNoIf yes, please explain:Do you have any medical conditions, handicaps, or impairments that make certain work or physical activities difficult for you?YesNoIf yes, please explain:Are you currently taking any prescription medication?YesNoIf 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?YesNoHave you been diagnosed with HIV or AIDS?YesNoBACKGROUND INFORMATIONDo you have a probation or parole officer?YesNoIf yes, please indicate their name and phone number:Do you have any court cases or legal issues pending?YesNoIf yes, please describe and provide date:Please list criminal convictions below:Describe Conviction:FelonyMisdemeanorNo ConvictionsDate:County or Location:------------- Describe Conviction:Felony