Community Fridge Spring 2026 Intake Form

Thank you for your interest in the Community Fridge Cooking Program at Essex Market. 

Please complete this short form so we can learn more about your participant and make sure the program is the right fit.

This program runs every Monday, 1:00 PM – 3:00 PM, starting May 4th

The fee is $75 per session.

After we review your form, a member of our team will follow up with next steps.

Questions? Contact us at info@culikid.org.


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Email *
Participant's name: *
Participant's birthdate: *
Make sure to include their birth year and not the current year.
MM
/
DD
/
YYYY
Guardian's name: *
Guardian's email address: *
Guardian's phone number: *
What is the participant's first language?
 *
Guardian's relationship to participant
How did you hear about Community Fridge?
 *

What is your goal for this program?

 *
Required

How comfortable is the participant in the kitchen right now?

 *
Required

What type of support does the participant typically need?

 *
Independently
With verbal prompting
With demonstration
With physical guidance
Multi-step sequences (3 or more steps in order)
2-step sequences
Single-step instructions

How does the participant handle safety-related tasks?

 *
Independently
With verbal prompting
With demonstration
With physical guidance
Has not done this
Using a knife
Hot stove or oven
Hot liquids or pots

How long can the participant comfortably do the following, with normal breaks?

 *
2 Hours
1 Hour
30 Minutes
Not Sure
Physically active
Stay Focused

Are any of the following difficult for the participant?

Does the participant have any food allergies, dietary restrictions, or food aversions? If so, please describe them below.
*
Is there anything else you'd like us to know about the participant? *
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