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Foundations Program

Participant Application

Thank you for your interest in the Brazen Table virtual program. Please fill in the application below. We look forward to hearing from you and will be in touch soon. If you have been referred by another organization, please be sure that organization has also filled out a Referral Form on your behalf.

Brazen Table - Foundations Participant Application

Program Details

What you get

An 6-week interactive hands on experience
All work materials are provided
$200 Weekly Stipend
Employability Skills
Personal Development
Food Handler’s Certification
1-on- 1 Case Management

General Information

First Name *

Last Name *

Other name(s), if any

Age *

Date of Birth *

Gender * Gender

Sexual Orientation * Sexual Orientation

Pronouns * Pronouns

Race and/or Ethnicity (check all that apply) *

Arabic/Middle Eastern

African American/Black

Asian

Caucasian/White

Indigenous/Native American

Pacific Islander

Latino/Latina/Latinx

I’d rather not disclose

Self-DescribeSelf-Describe

Cell Phone *

Email *

I agree to receiving texts or calls directly related to the program: *

Yes

No

Do you have documentation that allows you to gain employment in the United States? *

Yes

No

What income bracket does your household fit into? *

$0 - $10,000

$10,001 - $15,000

$15,001 - $20,000

$20,001 - $25,000

$25,001 - $30,000

$30,001 - $35,000

$35,001 - $40,000

Greater than $40,000

Emergency Contact

This should not be your case manager.

Name *

Phone Number *

Relationship *

Alternate Phone Number

Referral Agency

Are you currently receiving services from a community based organization? *

Yes

No

What organization(s) are you receiving services from?

Do you have an active Case Manager? What is their name? What organization are they from?

Brazen Table values collaborating with other community based organizations to ensure the success of our participants. Please provide the email and phone number of your the current case manager you are working with.

How often do you communicate with your case manager?

Weekly

Bi-Weekly

Monthly

OtherOther

Please check all types of support or services you receive from this organization:

Survivor Support Group

Therapy or Counseling

Case Management

Food Assistance

Housing Assistance

Clothing Assistance

Childcare

Employment

Educational Classes

Legal Assistance

Domestic Violence Support

Financial/Bill Assistance

Medical/Health Care

Transportation

Vocational Training

Other

Are there additional services you would find helpful?

Housing + Access

Will you have a consistent place to sleep during the program? *

Yes

No

What is your current living situation? *

Rent apartment/house

Permanent subsidized housing

Residential Treatment Program

Single Room Occupancy

Transitional Housing

Halfway House

Safe House

Friend

Relative

OtherOther

If staying in a residential program or safe house, what is the name of the facility? When is your move-out date?

What is your plan for securing housing after the residential program?

What is your main source of transportation? *

Personal Vehicle

Public Transportation

Ride Share (Uber, Lyft, etc.)

Friends and/or Family

Programmatic Questions

You should expect to spend 18 hours a week for 6 weeks to complete the program. If you have any children or others that you are responsible for their care, how do you plan to balance the workload for this program while caring for them?

If you are currently employed, how do you plan to balance the workload for this program while working?

Personal Goals + Expectations

Why do you want to participate in Brazen Table: Foundations? *

What do you expect from participating in Brazen Table: Foundations? *

What are your personal strengths? (Examples: detail-oriented, loving, compassionate, etc.) *

What questions do you have before starting the program?

What else would you like for us to know about you?

How did you hear about Brazen Table? *

If you are human, leave this field blank.

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4928 Fulton St, Suite A
Houston, TX 77009

Monday through Sunday // 7:30AM–2:00PM
832-962-7656

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Last Name

Email Address *

If you are human, leave this field blank.

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