Food Jobs Work Adult Culinary Program is a 12-week course for adults with barriers to employment. Our goal is to get you ready for full-time employment in the foodservice industry. The course is offered at no cost to you. We offer an attendance-based stipend during the course to cover basic living expenses. Students must be referred from a case manager, peer support specialist, or similar non-relative person with a letter or email the person’s reliability, sobriety (at least two weeks), and access to housing and transportation. Please complete this form to be considered!

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Have you had any circumstances that made employment difficult, such as past incarceration or other justice involvement, addiction, homelessness or near homelessness, abuse, poverty, or other barriers? (You do not have to tell us details.) *

• Yes
• No

Food Jobs Work is intended for adults with barriers to employment. While you do not qualify at this time, please stay connected with us as we grow. In the future we will have self-pay options for individuals without these barriers.

Do these challenges include a physical or psychiatric diagnosis? This can include diabetes, depression, or ADHD. (You do not have to tell us details.) *

• Yes
• No

Full Name *

First

Last

City Where You Live *— Select Choice —BentonBryantConwayJacksonvilleLittle RockMaumelleNorth Little RockPine BluffSherwoodOther

Write In Your City:

Email Address *

Phone Number *

Date of Birth *

Social Security Number (for federal grant reporting)

Referring Organization / Where you have case management *Arkansas Rehabilitation Services (ARS)Arkansas Workforce Center at Little Rock (S. University)Freshly Renewed TransitionalGoodwill ArkansasJericho WayMagnolia Recovery CommunityNatural State RecoveryNext Step Recovery HousingOur HouseWolfe Street CenterOther LocationNone – I need a referral

Please write in location for case management

Name of Case Manager / Peer Support Specialist *

Email of Case Manager / Peer Support Specialist *

Phone Number of Case Manager / Peer Support Specialist *

Which cohort would you like to join?

• Little Rock – Sept. 8 – Nov. 5
• Pine Bluff – Oct. 13 – Jan. 16
• Little Rock – Future Cohort
• Pine Bluff – Future Cohort
• Online Training

This program requires a serious commitment of time and attendance. If accepted, will you be available on Monday through Thursday, 9 a.m. to 5 p.m. through the entire program? *

• Yes
• No

Explain your answer: *

Are you currently employed? *

• Yes
• No

Will you be able to adjust your schedule, if necessary, to Fridays, evenings M-Th, and weekends only during the course? Add details if needed. *

Why do you want to join the Food Jobs Work culinary program? *

Tell us about your prior cooking or restaurant experience. Home cooking is okay! *

Male or Female Clothes Sizing *

• Male
• Female

T-Shirt Size (unisex sizing) *Extra SmallSmallMediumLargeExtra Large2X3X

Pants Waist

Selected Value: 35

Pants Size

Selected Value: 16

Blouse Size

Selected Value: 16

Chest schedule, about

Chest Measurement

Selected Value: 42

Questions or Comments

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