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Lucky Ones Coffee Application
A coffee shop that employs and empowers individuals with disabilities
Participants Full Name *
Participant (or Legal Guardian) Email *
Participant (or Legal Guardian) Phone Number *
Date of Birth *
MM
/
DD
/
YYYY
Highest Level of Education Completed *
School you are currently enrolled in?
Do you have your own transportation or reliable way of getting to and from work? *
Have you ever been employed or received job training before? *
Who referred you to this program? *
Relationship to this person (if they are with an employment agency what agency do they work for) *
Contact Information for the person who referred you (Email and Phone Number)
What length of shifts are you comfortable working? *
What days of the week are you available to work? *
Required
What Position are you most interested in working? *
How do you best feel supported? *
What would you say are your two biggest strengths? *
What are the two biggest areas you would like to improve?
What goals do you have for working at Lucky Ones Coffee?
Please Rate on the Following Scale
1= No interest/skill in this area
2= Slight interest/skill in this area
3= Moderate interest/skill in this area
4= High interest/skill in this area
5= Extremely high interest/skill in this area
Comfort working around noise *
Greeting customers in a positive manner
Clear selection
Following basic instructions from a supervisor
Clear selection
Serving and making hot beverages
Clear selection
Helping to take in and track inventory
Clear selection
Entering a customers order into a computer
Clear selection
Answering customers questions and giving recommendations
Clear selection
Taking on leadership
Clear selection
Doing dishes and mopping
Clear selection
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