Kitchen PREP

Kitchen PREP

Community Kitchen Training Program | Participant Registration Form
This program is offered by the Youth and Family Wellness Camp in partnership with
the Kenora Community Justice Centre (CJC) and Kenora Chiefs Advisory (KCA).

Program Location: Kenora CJC, 33 Main Street South, Kenora ON, P9N 1S8
For more information, please email wellness.camp@kenorachiefs.org
Name

First NameLast Name
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Age
Gender (optional)

Other
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Community / First Nation Affiliation (if applicable)
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Do you have a Government-Issued Form of ID?
Form of ID:
Do you have your Social Insurance Number?
Do you have a Bank Account?
Emergency Contact Information
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Number
Please enter a valid phone number.Format: (000) 000-0000.
Referral Information
Are you being referred by a program, school, or organization?
If yes, please provide details below:
Referring Agency / School:
Contact Person

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Program Interest & Experience
Why are you interested in joining the Kitchen Training Program?
Have you participated in any other training or employment programs?
If yes, please describe briefly:
Do you have any prior kitchen, cooking, or customer service experience?
If yes, please describe briefly:
Supports & Availability
Are there any supports you may need to help you succeed in this program? (e.g. transportation, meals, schedule flexibility, mental health supports, childcare)
Are you able to participate in the full 6-week program?
Preferred method of contact:
Participant Agreement

By signing below, I confirm that:
• I am interested in participating in the Community Kitchen Training Program beginning January 2026.
• I understand this is a pilot program that includes hands-on training, mentorship, and paid placement hours.
• I agree to participate respectfully, follow safety guidelines, and communicate with staff if I require support or need to miss a session.
Participant Signature:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent / Guardian Signature (if under 18)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Kitchen PREP

Emergency Contact Information

Referral Information

Program Interest & Experience

Supports & Availability

Participant Agreement