Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone Number *

(###)

###

####

How do you prefer to be contacted? *

Primary Phone

Email

Mail

Do you have a valid drivers license? *

Yes

No

Ethnicity *

African-American/Black

Asian

Caucasian

Hispanic

Other

Household Income Level *

$45K - Above

$34K-$44K

$22K-$33K

Below $21K

Emergency Contact *

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

####

Are you currently under a doctor's care? *

Yes

No

Do you have any known illness or communicable disease that could be transmitted through food handling? *

Yes

No

Are you currently taking any prescription medications? *

Yes

No

Do you have any physical conditions that will limit your ability to stand or lift in a kitchen environment? This includes standing for up to 4 hours at a time and lifting boxes up to 50 pounds. *

Yes

No

Did you graduate high school? *

Yes

No

Currently Attending

Have you attended a trade school? *

Yes

No

Have you attended college? *

Yes

No

Are you involved in any type of drug or alcohol rehabilitation program? *

Yes

No

Do you give permission for random drug testing? *

Yes

No

Have you been convicted of a felony within the last five years? *

Yes

No

Do you have any court cases pending? *

Yes

No

Do you give our agency permission to perform a background check? *

Yes

No

How will you get to class each day? *

My own vehicle

Someone will drive me

Bus

Walking

Have you previously applied to attend the Culinary School? *

Yes

No

Marital Status *

Married

Divorced

Single

Widowed

What do you hope to achieve through completing the program? *

Get a job

More work hours

Increased pay

Become a better cook

Other

What is your current employment status? *

Working Part Time

Working Full Time

Unemployed

Are you receiving benefits from *

Disability

Social Security

TANF

WIC

Other

None

What is your current living condition? *

Living in my own home or apartment

Living with a friend or family member

Living in transitional housing or a shelter

Other