LIFT Application 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 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: FelonyMisdemeanorNo Convictions Date: County or Location: ------------- Describe Conviction: FelonyMisdemeanorNo Convictions Date: County or Location: ------------- Describe Conviction: FelonyMisdemeanorNo Convictions Date: County or Location: ------------- Describe Conviction: FelonyMisdemeanorNo Convictions Date: County or Location: ------------- Describe Conviction: FelonyMisdemeanorNo Convictions Date: County or Location: PLEASE SEND ALL REQUIRED DOCUMENTS TO: Freestore Foodbank 3401 Rosenthal Way Cincinnati, Ohio 45204 For more information, please call 513-482-7292. 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, and/or have a doctor's release to participate. Signature:(type your full name) Date: × Share This FacebookTwitterLinkedInEmail