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Name *

First

Last

Address - Street, City, Province, Postal code *

How long have you been at this address? *

Phone # *

Alternate #

D.O.B. *

Email *

Are you fluent in english?

• yes
• no

Marital status

• single
• married
• common-law
• separated
• divorce/widowed

Number of dependant family members

Under 18 years of age

Do you have reliable childcare?

• yes
• no

Ethnicity: *

• Treaty/Status
• Non-status
• Metis
• Inuit
• Immigrant
• Non-indigenous

Are you a member of a Band or Metis Settlement? If so, which one?

Are you on Social Assistance/Income Benefits *

• yes
• no

If so, who is your Social Worker?

If NOT on Social Assistance/Income Benefits what is your source of income?

EDUCATION - Grade level completed?

Year completed:

Location education was completed:

What is your reading grade level?

What is your writing grade level?

Computer Skills: *

• Beginner (little to no computer skills)
• Basic (search internet, play games, email)
• Advanced (attach emails, knowledge in word, excel, build resume, use outlook and calendar)

Do you have a resume? *

• yes
• no

Did you create your own resume?

• yes
• no

Do you have any of the following certificate training?

• First Aid/CPR
• WHMIS
• TDG
• Flag Person
• Food Safe
• Pro-serve
• CSTS
• Sell-Safe (Cannabis)

Do you have access to a computer/chrome book while participating in the online program?

• yes
• no

To better asssist you in successfully completing the program, are there any diagnosed learning disabilities you may have?

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