Application for Land or Sea Culinary and Hospitality Education & Training
SECTION 1: PERSONAL INFORMATION
Legal Name:
*
First Name
Middle Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Gender:
*
Male
Female
Prefer no to anser
U.S. Citizenship Status:
*
U.S. Citizen
Lawful Permanent Resident
SECTION 2: CONTACT INFORMATION
Primary Number:
*
Cell Phone
Alternative Number
Relative or Other
E-mail Address:
*
example@example.com
Do you agree to receive communication via?
*
Email
Text
Both
Resident Address:
*
Street Address
County
City
State
Zip Code
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
SECTION 3: DEMOGRAPHIC INFORMATION
Race (select all that apply):
*
African American / Black
White
Asian
American Indian / Alaska Native
Hawaiian / Pacific Islander
Prefer not to answer
Ethnicity:
*
Hispanic or Latino
Non Hispanic nor Latino
Considered having a disability:
*
Yes
No
Prefer not to answer
SECTION 4: EDUCATION STATUS
Highest Grade Completed:
*
Are you currently attending school?
*
Yes
No
High School Diploma / GED?
*
Yes
No
Currently in an IEP (Individualized Education Program)?
*
Yes
No
Have you already earned an associate or bachelor's degree?
*
Yes
No
If you have earned your associate or bachelor's degree what college / university did you attend?
*
N/A, if this question does not apply.
SECTION 5: EMPLOYMENT STATUS
Current Employment Status:
*
Employed Full-Time
Emplohed Part-Time
Unemployed
Never Worked
Looking for Work?
*
Yes
No
SECTION 6: INCOME & PUBLIC ASSISTANCE
Annual Household Income
*
Family Size
*
Are you receiving any of the following (check all that apply):
*
Temporary Assistance for Needy Families (TANF) / Cash Assistance
Supplemental Nutrition Assistance Program (SNAP) / Food Stamps
Social Security (SSI / SSDI)
General Assistance
Free / Reduced School Lunch
None
SECTION 7: BARRIERS TO EMPLOYMENT
Check all that apply:
*
High School Dropout (not enrolled and no diploma or GED
Basic Skills Deficient (low math or reading level)
English Language Learner
Youth in or aged out of foster care
Homeless or Runaway
Pregnant or Parenting
Offender (history of arrest or conviction)
Living in a high-poverty area
Low-income individual
Disability (physical, mental, or learning)
Recently relocated du to natural disaster or other hardship
Cultural barrier or isolated community
Within 2 years of exhausting TANF benefits
Long-term unemployment (27+ weeks)
Needs additional assistance to enter or complete an educational program or to secure and hold employment
None
SECTION 8: EMERGENCY CONTACT
Name
*
First Name
Last Name
Relationship
*
Phone Number
*
Please enter a valid phone number.
SECTION 9: OTHER QUESTIONS
Have you lived in Michigan for a year or longer?
*
Yes
No
Will you be ready to start classes by August 15, 2025?
*
Yes
No
How were you referred to us?
*
Community Event
Social Media
Word of Mouth
Other (please specify)
SECTION 10: SIGNATURES
I hereby certify that the information provided in this application is true and complete to the best of my knowledge. I understand that any false or misleading information may result in disqualification from the program. I acknowledge that submission of this application does not guarantee acceptance, and that additional documentation may be required upon approval to verify my eligibility and complete enrollment. By submitting this application, I agree to comply with all program requirements and guidelines.
Applicant Signature:
*
Date
*
-
Month
-
Day
Year
Date
Parent / Guardian Signature (if under 18):
Date
-
Month
-
Day
Year
Date
Submit Application
Submit Application
Should be Empty: