NEW MILFORD COMMUNITY CULINARY PROGRAM APPLICATION

All information provided is strictly confidential.  Please print.

Full name: ____________________________________                    Date: _____________________

Street Address/Town/Zip:____________________________________________________________

Phone(s): ____________________________________ Date of Birth: ________________________

Social Security # (or INS#): __________________________  Marital Status: __________________

Gender: ______  # and ages of children in household: _____________________________________

Mode of transportation: _______________________ Do you have a license? __________________

Race/ethnicity (optional): ______________ Do you speak a 2^nd language? _____________________

How did you learn about this program? _________________________________________________

Why do you want to join this program? _________________________________________________

_________________________________________________________________________________

Social Services

Other agencies or service providers involved with you:  (such as DSS, Dept of Labor, community mental health agency) _______________________________________________________________

Contact person at agency: ____________________________________________________________

Address: __________________________________________________________________________

Phone: __________________________

Are you currently receiving any of the following?

            __ Cash assistance                   __ SSD/SSI                             __ Dept. of Labor training funds

            __ SAGA Cash                        __ Food stamps                       __ Medicaid/SAGA/HUSKY

            __Housing assistance                __Unemployment

Education

Highest grade of schooling completed ____  High School Diploma? ____  G.E.D? ____

Name of school: _________________________________________________________

Have you ever attended college? _____________  Major course of study: ___________ Degree?  ____

Did you receive special education or resource help in school? _________________________________

Employment

Are you currently employed? __________

Starting with your most recent job please list your work experience:

Name of employer: ________________________ Start date: ___________ End date:____________

Job title: _________________________________ Supervisor’s name: ________________________

Reason for leaving: _________________________________________________________________

Name of employer: ________________________ Start date: ___________ End date: ____________

Job title: _________________________________ Supervisor’s name: ________________________

Reason for leaving: _________________________________________________________________

Name of employer: ________________________ Start date: ___________ End date: ____________

Reason for leaving: _________________________________________________________________

Have you ever been fired for any reason? ____ Explain: ____________________________________

What did you like best about your last job? _______________________________________________

What did you like least about your last job? _______________________________________________

Have you ever had a negative experience at work with a supervisor or co-worker? ________________

How did you handle it? _______________________________________________________________

Do you have any concerns regarding obtaining employment?  If so, please explain: _______________

Financial

What is your total family income? __________________________

How many family members reside in your household? _____________

__________________________________________________________________________________

Family-related

Where will each of your children be during the hours you are in the program?  List the name of the facility or school, address, telephone number and contact person.  Use the back of the page if needed.

__________________________________________________________________________________

Do you have a back-up child care plan? ________ Describe: _________________________________

Housing-related

Are you a homeowner or renter? _______  How long have you been at your current address? _______

If less than 2 years, what was your previous address? _______________________________________

Any housing issues/concerns? _________________________________________________________

Legal

Do you have any prior convictions? _______ If yes, please list convictions: _____________________

Are you on probation? ______ Officer’s name/phone #: _____________________________________

Medical

Do you have any limitations or restriction in standing, sitting, walking, bending, stretching, lifting, reaching or grasping?

Explain: _________________________________________________________________________

List any recent surgeries: _____________________________________________________________

List any allergies: ___________________________________________________________________

List any medical problems: ____________________________________________________________

List any mental health diagnoses: _______________________________________________________

Are you taking any medications? _______ Please list them and the reason prescribed: _____________

Do you take your medications as prescribed? ______  If not, explain: __________________________

How many times were you sick in the last six months? ______________________________________

Name of Primary care MD: ____________________________________________________________

MD Address/phone#:_________________________________________________________________

Do you have medical insurance? _______ If yes, Company name: _____________________________

Policy #: _______________________________

PLEASE BRING YOUR INSURANCE CARD AND A PHOTO I.D. WITH YOU SO WE CAN MAKE A COPY FOR YOUR FILE.

Lifestyle

Do you have a history of substance abuse? __________

Are you currently using illegal drugs? ________ When was the last time you used drugs? ________

 __________________________What was your drug of choice?_____________________________

Do you drink alcohol? ______  How often/much per week? _____ When was the last time you had a

drink? ______________________

Are you involved in any recovery or 12 step programs?_____ If so, describe ___________________

Do you currently have a lot of stress in your life? _________________ If so, describe _____________

What do you like to do in your free time? _________________________________________________

Are there personal, professional, social or family obstacles that may interfere with your successful participation in this program?  If so, please explain:_________________________________________

Feel free to make any additional comments about yourself below.