Canada-British Columbia Job Fund Agreement Participant Intake Form

Transcription

1 Canada-British Columbia Job Fund Agreement Participant Intake Form PLEASE PRINT CLEARLY AND ANSWER ALL QUESTIONS ON THE FORM. IF YOU HAVE ANY QUESTIONS ABOUT THE FORM PLEASE ASK PROGRAM STAFF OR SEE THE ATTACHED DEFINITIONS PAGE. THANK YOU. Name of Program: ESS Program Agreement #: C16ESS0 Organization: SUCCESS Month: Year: Project Name: Youth BiiS Name: First Name Middle Name Last Name Date of Birth: / / Year Month Day Mailing Address: Street Address City / Town Postal Code Address: Phone Numbers: Daytime ( ) Alternate ( ) 1. Are you a: Canadian Citizen No Yes Permanent Resident No Yes Protected Person entitled to work in Canada No Yes 2. Gender: Male Female Other Youth BiiS intake form Page 1 of 7

2 3. Do you self-identify as a Visible Minority? No Yes Prefer not to answer 4. Do you self-identify as a Person with a Disability? No Yes 5. Do you self-identify as an Indigenous Person; that is, First Nations, Metis or Inuit? No Yes Prefer not to answer If yes, please check one: First Nations Métis Inuit Prefer not to answer Where do you live? On reserve Off reserve Prefer not to answer 6. Did you immigrate to Canada? No Yes If yes, what year did you immigrate to Canada? 7. What is the highest level of education you ve attained: (please check one) Less than high school High School diploma or recognized equivalent Some post-secondary Non-university certificate or diploma such as a trades certificate Diploma University 8. Which best describes your pre-intervention employment status: (please check one) Employed Self Employed Unemployed In school or training Not in the labour force If you checked Employed or Self Employed above: How many hours do you work in an average week? hours How long have you been employed by your current employer?. years (i.e years for 1 year, 3 months. To calculate months less than 12, divide # of months into 12 (3 12=.25) Youth BiiS intake form Page 2 of 7

3 What is your employment type? (check one) Seasonal Temporary Casual Permanent None of the above What is your average hourly wage? $ per hour How long have you been employed in this job? years months For office use only: What sector does this occupation fall under: NAICS (2012) code: What is the participant s occupation: NOC code: 9. Are you an apprentice? No Yes 10. Are you registered with the Industry Training Authority (ITA)? No Yes 11. What is your EI status? (please check one) EI Claimant Non-EI Claimant If EI Claimant was indicated above, have you received, or are you receiving Employment Insurance (EI) benefits: (please check one) Currently In the last month In the last 3 months In the last 36 months (3 years) In the last 60 months (5 years) Were these maternal/parental benefits? No Yes 12. Are you currently receiving Income Assistance (IA)? No Yes Youth BiiS intake form Page 3 of 7

4 Surveys and Testimonials 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"). Personal Information 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 or FOI.Requests@gov.bc.ca. Consent and Agreement 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. Name (print name) Signature Date Youth BiiS intake form Page 4 of 7

5 1. Business Proposal Please provide all relevant information to the points listed below: 1) Briefly describe the idea for your business and why you have chosen it. 2) Identify why you think this is a good business idea. 3) What sort of research have you done? 4) Whom have you talked to about it and what was their reaction? 5) What personal and entrepreneurial qualities you possess? 6) When is your tentative date of business startup?

6 2. Financial Information 1) What is the estimated startup cost? e.g. Business licensing, equipment, inventory etc. 2) Estimated monthly working capital for 6 months? e.g. Salary/labour cost, rent/lease etc. 3) What is your source of fund? e.g. personal savings, business loan, angle investment, family/friends source. 4) Available fund for investment 3. Privacy Agreement Youth Entrepreneurship Program Commitment to Privacy Statement 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. I would like to hear from Youth BIIS periodically about other S.U.C.C.E.S.S. programs, services, workshops, training, networking or opportunities that may be of interest. 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. Signature of the Applicant: Date: Printed Name: Where did you hear about Youth BiiS Program? Youth BiiS Website SUCCESS Website Social media Magazine/ Newspaper Family/Friend Referral Google search Youth BiiS Flyer/Poster location Library / Library website other sources

7 Youth-BIIS Client Coaching Action Plan Name of the Client: Purpose of the Action Plan This action plan outlines the activities designed to help you reach your goals in obtaining appropriate information and resources regarding establishing business in BC. Short Term Goals: Increase start up and business management skills Gain sector specific business knowledge Get require skills and/certification Write business plan Expand business network and increase business tie Get business loan Gain startup confidence Others (Please specify): Long Term Goals: Start / Launch business successfully Action Plan (to be completed within six months) Activities/Actions Note Referral to Other Services Settlement/Professional Services URL/ Contact Information