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 * Female Male Non-Binary Transgender I'd rather not disclose Self-Describe Gender Sexual Orientation * Select an option Bisexual Gay or Lesbian Straight/Heterosexual Queer Asexual I'd rather not disclose Self-Describe Sexual Orientation Pronouns * Select an option She/Her/Hers He/Him/His Them/Their/Theirs I'd rather not disclose Self-Describe 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. Submit Δ