APPLICATION FOR THE CULINARY CORNERSTONES TRAINING PROGRAM The Culinary Cornerstones EXPLORERS Training Program is a 6-week intensive, entry-level program that provides job training, support services and hands-on demonstrations in the food service industry to individuals who are unemployed or underemployed. The program includes the following: ServSafe sanitation training Food handler s certification Training of all aspects of kitchen duties Basic culinary skills Life skills Individual and Group counseling. Instruction and activities are designed to help students determine if the food service industry is a career path for each person. If a student chooses the industry as a professional path, urishkc will refer the student to our Career Path program that will start in January 2019, and will include continued financial, training, and job support services. Financial Provisions Paid to Students for Training $10.00 Hourly Pay Six-week program Bus Pass Monthly, As Needed 2 Months For more information or questions about the application contact Chelsi Flores at 816-800-0886 YOU ARE INVITED TO ATTEND Open House on Sept. 9 from 2-4 pm or Sept. 11 from 4-6 pm 750 Paseo, Kansas City, MO. Staff will provide a review of EXPLORER program and assist in the application process. APPLICATION CHECKLIST Include this Application Checklist Page 1. Eligibility Requirements and Program Expectations on Page 2. Go over this form with someone who works with you at another social services agency. Make sure it is signed by applicant and referral agency representative. Application for Admission Page 3 and Page 4 completed by applicant.
EXPLORERS Eligibility Requirements and Program Expectations PAGE 2 It is essential that you understand and agree to the requirements and expectations of the program. Please place your initials next to each line indicating that you have read and agree to these basic requirements. I must be 18 years old or older. I will provide my state issued identification and complete paperwork for payroll processes. I understand I must be physically able to stand for up to four hours. I understand that I must be able to see and hear within the normal ranges with reasonable accommodations. I understand that I must be able to read, write and do math at an 8 th grade level. I understand that if I have a history of convictions involving sexual offenses or arson, I am not eligible for this program and that a history of violent crime will be reviewed on a case-by-case basis for eligibility. I understand attendance is mandatory and tardiness is unacceptable in this program. I understand that black shoes, black shirt and black pants are the required dress code. I understand that I must be drug and alcohol-free during program hours. I understand that I may be subject to random drug testing. I understand that if it is necessary for me to withdraw from the program, I must do so by calling and speaking directly to the Culinary Cornerstones Director of Community Care or the Culinary Instructor of CCTP. I understand that if my enrollment is terminated for any reason, all partnering agencies will be notified, and all financial supports will be terminated. I understand that in order to graduate and receive an official certificate of completion, I must successfully complete all the required hours, assignments and pass all written and practical examinations as assigned by instructors. I,, acknowledge that I have received a copy of the Applicant s Name (Print) PROGRAM REQUIREMENTS AND EXPECTATIONS and meet the basic eligibility requirements and agree to meet the program expectations to participate in the Culinary Cornerstones EXPLORERS Training Program. Applicant s Signature Referral Agency Representative s Signature
PAGE 3 Application for EXPLORERS Admission CONTACT INFORMATION Legal Name: Last/Family First Middle/Maiden Social Security Number: - - Permanent Mailing Address (include street & number, city, state, and zip): Correspondence will be mailed to this address. Own Rent Relative Transitional Housing (specify:) Shelter (specify: ) Other: Home Phone: Cell Phone: Email Address: (Print clearly.) of birth: / / Month Day Year Gender: Male Female Nation of Citizenship: United States United States Veteran Other: Immigration Status: Permanent Resident Alien (copy required) Refugee (copy required) Visa Type (copy required) Voluntary response is requested. This information will not be used in a discriminatory manner. (Select only one) American Indian or Native Alaskan Asian or Pacific Islander Black (non- Hispanic) Hispanic White (non-hispanic) Do you have Health Insurance? Medicaid Medicare Other Insurance Please list Insurance EDUCATION HISTORY Please mark your highest level of education Some High School High School Diploma (no diploma) : High School: GED Certificate : Vocation Training : City/State: Some College (no diploma) College Diploma : Other (Vocational Training, College, University) City/State: EMPLOYMENT HISTORY Position/Activity: Employer: (name, city, state) From: (month/year) To: (month/year) Name: EMERGENCY CONTACT Relationship to Student: Home Phone: Cell Phone: Work Phone: Address: (include street & number, city, state, and zip)
PAGE 4 CRIMINAL HISTORY PLEASE ANSWER ALL QUESTIONS HONESTLY. THE INFORMATION COLLECTED BELOW IS NOT USED TO DETERMINE ELIGIBILITY. Do you have any warrants, court dates or other upcoming legal issues? If yes, please explain: Have you ever been convicted of a misdemeanor? If yes, please explain: Have you ever been convicted of a felony? If yes, please explain: Are you on probation? CCO Name: Phone: Are you on work release? CCO Name: Phone: Background Check Release Our aim at urishkc is to assist students in achieving self-sufficiency. To this end, it is essential that we are aware of any barriers to success that our applicants face. To aid in this process, we ask that all applicants consent to a criminal history search. I agree to allow (referring agency) to conduct a criminal history search. I understand that failure to disclose criminal convictions is grounds for being denied enrollment to the Culinary Cornerstones Training Program. Initials: FINANCIAL AND SUPPORTIVE SERVICES PLEASE ANSWER ALL QUESTIONS HONESTLY. THE INFORMATION COLLECTED BELOW IS NOT USED TO DETERMINE ELIGIBILITY. Are you receiving or have you ever received any of the following benefits or services? Social Security (including SSI and SSDI): Amount: $ DSHS Benefits (including Housing, Child Support, Medical): Amount: $ Supplemental Nutrition Assistance Program (SNAP) / Food Stamps: Amount: $ Do you eat at the Kansas City Community Kitchen (750 Paseo)? How often: Do you visit any other Food Pantries / Soup Kitchens? How often: Temporary Aid to Needy Families (TANF): Amount: $ WIC: Medicare: Medicaid: Veteran s Benefits: Amount: $ Veteran s Health Care: Amount: $ Employment Income: Amount: $ Unemployment Benefits: Amount: $ Child Support: Amount: $ Other: Amount: $
Applicant s Name (Print) REFERENCE FORM I authorize the person completing this reference request to respond fully to all questions listed on this form. PAGE 5 Applicant s Signature te: Reference may include previous employer, family member, friend or probation officer. The individual named above has applied for admission to the Culinary Cornerstones Training Program, a program sponsored by urishkc, and has given your name as a personal reference. Kindly return this form to the applicant within 48 hours in a sealed envelope with your signature across the flap or mail directly to: urishkc, Attn: CCTP Reference Form, 11 East 40 th Street, Kansas City, MO 64111, or fax to Chelsi Flores, 816-561-4939. 1. How do you know the applicant? How long? EVALUATE Honesty Above Below Knowledge Dependability (trustworthy, follow-through and punctual) Responsibility (accountable for actions) Interpersonal Skills (relating to others and coping with difficult situations) Maturity (acts and speaks with thought and control and is able to ask for help) Initiative (willing to take charge or responsibility) Sound Judgment (makes good choices) Adaptability (ability to adjust to change) Self-Expression (awareness of behavior) _ Signature of Reference _ Print Name of Reference Telephone/Address
Applicant s Name (Print) REFERENCE FORM I authorize the person completing this reference request to respond fully to all questions listed on this form. PAGE 6 Applicant s Signature te: Reference may include previous employer, family member, friend or probation officer. The individual named above has applied for admission to the Culinary Cornerstones Training Program, a program sponsored by urishkc, and has given your name as a personal reference. Kindly return this form to the applicant within 48 hours in a sealed envelope with your signature across the flap or mail directly to: urishkc, Attn: CCTP Reference Form, 11 East 40 th Street, Kansas City, MO 64111, or fax to Chelsi Flores, 816-561-4939. 2. How do you know the applicant? How long? EVALUATE Honesty Above Below Knowledge Dependability (trustworthy, follow-through and punctual) Responsibility (accountable for actions) Interpersonal Skills (relating to others and coping with difficult situations) Maturity (acts and speaks with thought and control and is able to ask for help) Initiative (willing to take charge or responsibility) Sound Judgment (makes good choices) Adaptability (ability to adjust to change) Self-Expression (awareness of behavior) _ Signature of Reference _ Print Name of Reference Telephone/Address