Intake Application Form

Intake Application Form

Name

Date of Birth

Mailing Address

Email Address

Phone Numbers

e.g. (604)111-1111
e.g. (604)111-1111

1. Are you a:

Enter the number of hours
(i.e. 1.25 years for 1 year, 3 months. To calculate months less than 12, divide # of months into 12 (3 ÷ 12= .25)
Enter the wage per hour
Enter the number of years, if not applicable leave it blank.
Enter the number of months, if not applicable leave it blank.
*What is ESS?
All Employment Services and Supports Program Participants are required to complete two satisfaction surveys at approximately 3 months and 12 months following completion of their training ("Surveys"). Each survey will ask basic questions about your satisfaction with the training and whether the training met your needs.

You may also be asked if you wish to, or may volunteer to, provide a testimonial regarding your Employment Services and Supports Program training experience ("Testimonial").

All personal information in the Participant Intake Form, the Surveys, any Testimonial and other information related to your participation in a Employment Services and Supports Program training opportunity (“Personal Information”) is collected pursuant to sections 26(c) and 26(e) of the Freedom of Information and Protection of Privacy Act. This information will be used for administrative and evaluation purposes, including to determine your eligibility for participation in Employment Services and Supports Program training, and, in the case of any Testimonial, may be
used and disclosed to publicly promote the Employment Services and Supports Program (“Purposes”).

The Government of Canada (“Canada”) provides funding for the Employment Services and Supports Program under the Canada-British Columbia Job Fund Agreement. Personal Information will be used to create reports about Employment Services and Supports Program in British Columbia that will be provided to Canada in aggregate form only. No personally identifiable information will be disclosed to Canada for this purpose.

If you have any questions about the use of this information, please contact Information Access Operations at 250-387-1321 or FOI.Requests@gov.bc.ca.

Effective as of the date set out below, and in consideration of the opportunity for me to participate in Employment

Services and Supports Program training, I:
• Certify that all of the information that I have provided in this form is accurate and complete;
• Certify that I understand that I am expected to complete my training and complete the surveys;
• Consent to the collection (including indirect collection if I submit this form through an employer and/or any third party) and use of my Personal Information by the Province of British Columbia for purposes of accountability, quality assurance, research and evaluation of the Canada-BC Job Fund;
• Consent to my Personal Information being used to contact me to conduct the Surveys and to request a Testimonial.

I, the undersigned, hereby accept and agree to the above terms and conditions.

By signing this form, you certify that the information provided is accurate and complete to the best of your knowledge.

1. Business Proposal

2. Financial Information

3. Privacy Agreement

Youth‐BIIS is committed to protecting personal information by employing responsible information handling practices and respecting privacy information laws. We collect, use and disclose personal information in order to better meet your service needs, to ensure the safety of our participants, for statistical purposes, to satisfy government and regulatory obligations, and to inform you about S.U.C.C.E.S.S. programs and services.

By signing below, I am indicating that I understand that the Youth‐BIIS program will collect, use and disclose my personal information contained within this Application for the Youth‐BIIS program for the above‐noted purposes only, and I consent to the release of my personal information by the Youth‐BIIS program to S.U.C.C.E.S.S. and the Government of BC which funds the Youth‐BIIS program.

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