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Lucky Ones Coffee Application
A coffee shop that employs and empowers individuals with disabilities
Participants Full Name *
Your answer
Participant (or Legal Guardian) Email *
Your answer
Participant (or Legal Guardian) Phone Number *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Highest Level of Education Completed *
School you are currently enrolled in?
Your answer
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? *
Your answer
Relationship to this person (if they are with an employment agency what agency do they work for) *
Your answer
Contact Information for the person who referred you (Email and Phone Number)
Your answer
What length of shifts are you comfortable working? *
Your answer
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? *
Your answer
What would you say are your two biggest strengths? *
Your answer
What are the two biggest areas you would like to improve?
Your answer
What goals do you have for working at Lucky Ones Coffee?
Your answer
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
Following basic instructions from a supervisor
Serving and making hot beverages
Helping to take in and track inventory
Entering a customers order into a computer
Answering customers questions and giving recommendations
Taking on leadership
Doing dishes and mopping
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