ENGAGE Enrollment Form - Cooking Up Hope (BENEFITS)

ENGAGE Enrollment Form - Cooking Up Hope (Benefits)
Welcome to “Cooking Up Hope,” a monthly program that allows parents to connect with one another, ask questions about supporting their children in school, and prepare a delicious meal together. The program is free of charge, and all food preparation items are provided. Please complete all of the information below to enroll in this exciting program!

***BEFORE YOU BEGIN, you will need a copy of all the documents below.***
Below, please upload a copy of your government-issued ID. *

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Below, please upload a Summary of Benefits (must show the child's name and your address). You can access this information online at https://www.eppicard.com/ohedctaclient/setupPortal.recip *

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Name*

First NameLast Name
Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Occupation (Otherwise, type "unemployed.")*
Highest grade completed or degree earned:*
Gender*

MaleFemaleNon-binary
Emergency Contact Information
Emergency Contact's Full Name*
Emergency Contact's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact's Phone Number*
Please enter a valid phone number.
Please list any allergies, including food allergies (or type "none" if there are no allergies):*
How did you hear about this program?*
We at Center of Hope are responsive to our clients, and look for ways to connect them with resources that make life easier and more satisfying. Please indicate if you would like support with any of the barriers listed below:*

FoodClothingTransportationUnemploymentChild Support/CustodyHealthEducationHearing Support/Attorney ReferralsCSEA/LCJC Paperwork HelpSupport at my child's schoolAccess to mental health servicesQuestions about my child's school or progress at schoolNoneOther
If you selected "other," please specify:
Do you have any other goals you'd like Center of Hope to help you meet?*

Participating in the cooking classGaining a better understanding of my child's school systemGaining strategies for communicating with my child's teachers/principalObtaining a jobHigh School Diploma or GEDEnrollment in CollegeGaining a better understanding of how the Lucas County Juvenile Court System worksGaining a better understanding of how Children's Service worksGaining strategies for having difficult conversations with my childrenChild Support adjustmentsMental Health/WellnessDental/Health CareDriver's License ReinstatementOther
If you selected "other," please specify:
By signing below, I am acknowledging that the above information I provided is accurate. *

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Photo/Video Release
I, Full Name*, grant permission to Center of Hope Family Services, Inc. and employees the irrevocable and unrestricted right to reproduce the photographs and/or video images taken of me, for the purpose of publication, promotion, illustration, advertising, or trade, in any manner or in any medium.

I hereby release Center of Hope Family Services, Inc. and its legal representatives for all claims and liability relating to said images or video. Furthermore, I grant permission to use my statements that were given during an interview or guest lecture, with or without my name, for the purpose of advertising and publicity without restriction. I waive my right to any compensation.

I acknowledge that I am over the age of 18 and the legal guardian of the child.
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature*

Clear
Improving the life outcomes of adults, children, and families in urban settings.

419.861.4400 | 5461 Southwyck Blvd. Toledo, OH 43614 | www.cohfs.org
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ENGAGE Enrollment Form - Cooking Up Hope (Benefits)

Photo/Video Release