Park Heights Culinary Pathways – Participant Intake & Services Interest

Park Heights Culinary Pathways – Participant Intake & Services Interest

Please complete this form to help us understand your interests, needs, and eligibility for Park Heights Culinary Pathways. Your information will help Kanisa La Watu, YES at LHCBRC, Late Bloom, and Better Way of Life Financial coordinate support, training, and resources. By submitting, you consent to the collection and sharing of information as described below.
Basic Information

Tell us about yourself.
Full Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Date of Birth

MonthDayYear
Date
Preferred Pronouns
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Event & Referral

How did you hear about us?
How did you hear about Park Heights Culinary Pathways?*

Organization/Church/ProgramFriend/FamilySocial MediaFlyer/PosterOther
If Organization/Church/Program, please specify:*
Interests

Let us know your areas of interest.
Which of the following are you interested in? (Select all that apply)*

Culinary TrainingServSafe CertificationBusiness/EntrepreneurshipEmployment SupportCase Management/Support ServicesOther
ServSafe & Culinary Details

Tell us about your experience and certifications.
Do you currently have a ServSafe Certification?

YesNo
If yes, when does it expire?

MonthDayYear
Date
Do you have previous culinary training or experience?

YesNo
If yes, please describe:
Support & Case Management

Share your support needs.
What support services are you interested in? (Select all that apply)*

Housing AssistanceFood AssistanceMental Health SupportSubstance Use SupportTransportationChildcareOther
Logistics, Business & Financial

Help us understand your logistical and financial needs.
Do you need assistance with any of the following business services? (Select all that apply)*

TransportationChildcareBusiness PlanningFinancial CoachingFinancial Supports (Insurances, Legal, Investments, etc.)Other
Scheduling & Access

Tell us about your availability and access needs.
What days/times are you generally available for programming?*
Do you have reliable access to the internet?*

YesNo
Do you have access to a computer or smartphone?*

YesNo
In 6 months, what would you like to be different for yourself as a result of participating in this program?*
Consent

Your consent is required to participate and for us to contact you.
Information Sharing Preferences: May we share your information with partners for service coordination?*

All PartnersTraining Follow-up OnlyNo
Signature (Please sign below to confirm your consent and the accuracy of your responses)*

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Park Heights Culinary Pathways – Participant Intake & Services Interest

Basic Information

Event & Referral

Interests

ServSafe & Culinary Details

Support & Case Management

Logistics, Business & Financial

Scheduling & Access

Consent