Culinary Application Form by Greg Dietrich | Jul 14, 2021 "*" indicates required fields Name* First Middle Last Session Applying For* Session 1: March 2023 Contact & Demographic InformationGender* Male Female Date of Birth* Month Day Year Email* Primary Phone*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How did you hear about the Culinary Training Program?* Have you ever served in the US Military?* Yes No Do you have a criminal record including any recent criminal activity?*For the safety of our staff and other students, we conduct a criminal background check on all applicants. Recent criminal activity does not automatically disqualify you from the program but may affect your acceptance depending on the offense. Yes No If yes, please explain: Disability InformationPlease list and describe your disabilities, beginning with your primary disability.Disability #1: What is the disability?* Disability #1: Date of onset* MM slash DD slash YYYY Disability #1: This disability is a result of:* Disability #1: How does this disability limit your ability to obtain employment, work or live independently?*Disability #2: What is the disability? Disability #2: Date of onset MM slash DD slash YYYY Disability #2: This disability is a result of: Disability #2: How does this disability limit your ability to obtain employment, work or live independently?Disability #3: What is the disability? Disability #3: Date of onset MM slash DD slash YYYY Disability #3: This disability is a result of: Disability #3: How does this disability limit your ability to obtain employment, work or live independently?Please indicate below any programs or services with which you are involved at this time:*Select all that apply Adult Education and Literacy Program Behavioral Health Administration (BHA) Center for Independent Living Department of Rehabilitative Services (DORS) Department of Social Services (DSS) Developmental Disabilities Administration (DDA) Educational Institution (high school or post-secondary) The Arc Southern Maryland The Center for Life Enrichment (TCLE) The Connection Tri-County Council for Southern Maryland Education & Employment HistoryWhat is the highest level of education you completed?* No Formal Schooling Elementary or Secondary School Grade High School Certificate of Completion High School Diploma GED Post-Secondary Education Vocational / Technical Certificate Vocational / Technical License Which elementary or secondary school grade have you completed? Number of Credits earned toward degree: Are you currently a student, intern or in training, or volunteering?* Student Intern/In Training Volunteer None of the above If applicable, describe your current training /education.Do you have a current or previous IEP that you would be willing to provide?* Yes No Previous Employment*Please describe any food service training or experience you have had in the past.*Please describe a stressful workplace situation that you have experienced in the past as well as how you handled the situation.*TransportationIs your current address more than 40 miles from Chesapeake Church?* Yes No Do you have a valid driver's license?* Yes No Does your driver's license reflect your current address?* Yes No Do you have a reliable vehicle?* Yes No If someone else will be driving you to class, who will it be? If someone other than you will be driving you to class, who will it be? Physical Health HistoryAre you able to lift at least 30 pounds?* Yes No Are you able to stand for at least 2 consecutive hours at a time?* Yes No If no, please explain. Do you have allergies?* Yes No Please list allergies. Goals & Future EmploymentDo you desire employment after completion of the Culinary Training Program?* Yes No If no, please explain: Please describe your current career goals.*What do you hope to gain from participating in The Culinary Training Program of End Hunger (i.e. the kind of work you want to do or your independent living goals)?*Other comments, concerns or additional informationIf you are chosen to participate in the Culinary Training Program, would you be willing to participate in brief monthly surveys regarding your employment status?* Yes No Applicant AgreementStudent Attributes for Admission & Success*Personal: Self-care: Each student is responsible for their own self-care, including but not limited to personal hygiene and maintaining a clean uniform and professional appearance. (We will study this further in ServSafe Food Handling.); Self-control: The ability to self-monitor and self-regulate behavior, use appropriate language and actions as well as avoid inappropriate outbursts; Able to communicate with others and express needs; Able to handle changes in routine and can be flexible in fluctuating circumstances; Able to self-administer medications. Social-Emotional: Workplace appropriate behavior: Applicant must be able to appropriately self-regulate and be aware of his/her own actions in relation to those around them; Respect: Students must show respect for self and others; Able to work in a team as well as individually; Remain organized during tasks and classwork; Self-Management and motivation; Manage assigned tasks with limited reminders; Effectively manage mild stress. (e.g. time demands, constructive criticism and coaching) Cognitive: Cognitive skills sufficient to function in a kitchen and learning environment; Ability to understand basic instructions and carry out those instructions, consistently with low to moderate supervision; Comprehend written text at a 5th grade level; Read and follow basic recipes and directions, including the transfer to action; Ability to recognize a hazardous/unsafe situation/environment and act upon it appropriately; Reasoning sufficient to understand a critique and/or constructive criticism; Sustained attention to workload over time and goal achievement Vocational: The student has the desire and motivation to participate in a pre-vocational educational experience; Willing to learn about and use commercial kitchen equipment such as mixers, gas stoves, hoods, convection ovens, and dishwashers; Can use basic technology (cell phone, laptop, etc.) I agree that I have read the Student Attributes for Admission and Success.CommentsThis field is for validation purposes and should be left unchanged. 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