You are on page 1of 3

PARTICIPANT APPLICATION

It is important that you fill out this form completely, legibly and accurately. The information will be used by FEED NOVA SCOTIA to better understand each individual participant’s needs. All information will remain strictly confidential.
Full Name: Mailing Address: Telephone: Email: Date of Birth:
MM/DD/YY

Income Source (please check all that apply):
Income Assistance Caseworker Employment Counsellor Disability EDP Employed Phone Phone Other Fax Fax

Are you unemployed and not eligible for Employment Insurance (EI) benefits? Yes? No? In the past 5 years, have you received maternal/paternal employment insurance benefits? Yes? No? Education (most recent first):
Dates Attended (From / To) Institution Full or Part Time Graduated Yes / No Grade / Degree

Languages:
English: Other:
please specify

Speak

Read

Write

French:

Speak Speak

Read Read

Write Write

LK-004 Participant Application for Training X:\Policies & Procedures\Forms\Learning Kitchen\

© February 2010 / Revised Oct 2010

Work History: Please provide complete information on your last three jobs, starting with most recent. Food Service experience is not a requirement for admission to the program.
Employer: Address: City: Telephone: Position / Duties: Date of Employment (to/from): Reason for Leaving: Province:

Employer: Address: City: Telephone: Position / Duties: Date of Employment (to/from): Reason for Leaving: Province:

Employer: Address: City: Telephone: Position / Duties: Date of Employment (to/from): Reason for Leaving:
LK-004 Participant Application for Training X:\Policies & Procedures\Forms\Learning Kitchen\ © February 2010 / Revised Oct 2010

Province:

Volunteer Experience: Place Dates (From / To) Position / Duties Name of Supervisor

Please explain why you are applying to the Learning Kitchen:

Please provide any additional information you feel may be relevant:

I understand that the information on this application form will be used to consider my acceptance to the program and I certify that it is correct to the best of my knowledge. I permit FEED NOVA SCOTIA to check this information as they require. I also give permission to FEED NOVA SCOTIA to contact my Social Worker if I am in receipt of social assistance benefits. If accepted into FEED NOVA SCOTIA’s Learning Kitchen Program, I agree to follow all policies, rules and regulations. Applicant’s Name: Applicant’s Signature: Date: FEED NOVA SCOTIA’s Learning Kitchen 213 Bedford Highway Halifax NS B3M 2J9 T: (902) 457-1900 F: (902) 457-4500 learningkitchen@feednovascotia.ca
LK-004 Participant Application for Training X:\Policies & Procedures\Forms\Learning Kitchen\ © February 2010 / Revised Oct 2010