Cincinnati COOKS Application

    Complete this application accurately. The information provided here will be used by Workforce Development staff to better understand each potential trainee's situation and needs. All information will remain confidential. Applications must be properly filled out and completed.

    PERSONAL INFORMATION:

    First Name:

    Last Name:

    Gender:
    MaleFemaleTransgenderOther

    DOB:

    Email Address:

    Phone Number (numbers only, include area code):

    Current Address:

    Apt/Unit #:

    City:

    Zipcode:

    Neighborhood:

    SSN# (numbers only):

    What is your ethnicity background:
    *Please select one of the following that best describes you.

    Are you a U.S. citizen?
    YesNo

    If no, do you have a valid green card or passport?
    YesNo

    ELIGIBILITY REQUIREMENTS:

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

    If no, what is your primary language?

    This program is 10 weeks long and requires attendance from 8:00AM- 3:00PM, Monday through Friday. Are you able to adhere to this schedule for the duration of the program?
    YesNo

    If no, please reapply when you are able to meet the required hours. In person attendance is required in order to participate.

    Can you remain drug free and sober for the length of the 10 week training program?
    YesNo

    Sobriety during training hours is mandatory and all students are subject to drug testing for acceptance into program, and if intoxication is suspected at the training facility.

    Are you able to regularly perform required duties as assigned for full training period? Including but not limited to:
      • Standing at least four hours at a time without breaks or assistance.
      • Ability to bend and lift a minimum of 30 lbs.
      • Able to safely move around training area without difficulty or assistance.

    YesNo

    INFORMATION ON HOUSEHOLD, TRANSPORTATION & LIVING SITUATION:

    Housing Status:
    *Please select one of the following that best describes your housing status.

    If in Transitional shelter, please specify where:

    Are you at risk of being homeless?
    YesNo

    If Yes, call the CAP line 513-381-SAFE to start your journey to stability.

    Marital Status:
    *Please select one of the following that best describes your marital status.

    Are you the head of your household?
    YesNo

    How many minor children:

    Ages of minor children:

    If yes, how do you plan to maintain stable childcare during the program?

    Primary means of transportation:
    *Please select one of the following transportation options.

    EMERGENCY CONTACT INFORMATION:

    First Name:

    Last Name:

    Relationship to you:

    Phone Number (numbers only, include area code):

    EDUCATION AND EMPLOYMENT:

    Highest level of educational achievement:
    *Please select one of the following education options.

    EMPLOYMENT HISTORY:
    (Note: Industry specific experience is not a requirement for admission into the LIFT the TriState program).

    Employment Status
    Employed Full-timeEmployed Part-timeTemporary ServiceUnemployed

    Current/Most Recent Employer Information:

    Name of Supervisor:

    Supervisor's Phone (numbers only, include area code):

    Job Title:

    Duties/Responsibilities:

    Start Date:

    Last Date of Employment:

    Reason for Leaving:

    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 health insurance? If yes, what type?

    Do you have any regular ongoing medical or behavioral health appointments that interfere with our 8:00 am - 3:00 pm program hours?
    YesNo

    If yes, please explain:

    PHYSICAL AND MENTAL HEALTH:

    Overall Health

    Do you have any chronic medical conditions, or impairments that make certain physical activities difficult for you?
    YesNo

    If yes, please explain physical disabilities or restrictions:

    Past or current substance abuse issues:
    YesNo

    Cognitive or developmental disabilities or IEP?
    YesNo

    Mental health conditions:

    Are you currently taking any prescription medication that could cause any side effects, such as drowsiness, impaired motor skills, or impaired judgment when taking these medications?
    YesNo

    If yes, please list the names and schedule taken:

    Food allergies/dietary restrictions:
    Provide all that apply or type "N/A"

    INCOME AND PUBLIC BENEFITS:

    Are you a Veteran?
    YesNo

    If yes, VA Benefits:

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

    Other (Please explain):

    Are you currently receiving any of the following benefits or services?
    Food StampsMedicaid/AHCCCSCash AssistanceUtility AssistanceOtherNone

    Other (Please explain):

    Do you have a Case Worker/ Case Manager?
    YesNo

    Name:

    Agency:

    Phone (numbers only, include area code):

    Email:

    BACKGROUND INFORMATION:
    *Background checks are conducted on all applicants prior to enrollment.

    Do you have a probation or parole officer?
    YesNo

    If yes, please indicate your parole officer name and phone#:

    First Name:

    Last Name:

    Phone Number (numbers only, include area code):

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

    If yes, please describe and provide date:

    Have you been convicted of a violent felony in the last seven years?
    YesNo

    If yes, please explain:

    ADDITIONAL INFORMATION:

    Have you applied, enrolled or participated in the program previously?
    YesNo

    Class #:

    Incompletion Reason

    Referred by:

    How did you hear about our Workforce Training program?
    *Please choose from the following options.

    Please write a brief paragraph explaining why you are interested in this program:

    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 a drug and alcohol screening, and/or have a doctor's release for physical restrictions to participate.

    Signature:

    First Name:

    Last Name:

    Date: