First Name *

Last Name *

Phone *

Email *

Date of birth *

City *

Address *

Postal code *

Legal Status in Canada *

Permanent Resident

Citizen

Refugee with Work Permit

Employment Insurance (Select all that applies) *

Active Regular (EI)

Reach back (Regular EI in the past 60 Months)

Have worked full-time for any 5 years out of the last 10 years in Canada

Earned more than $2000 in insurable earnings and paid employee EI premiums on those earnings in at least 5 of the last 10 years (Note: the 5 years do not have to be consecutive years)

Income Assistance (BCEA – Non-PWD)

BCEA PWD Status

Not Sure

None of the Above

Employment Status *

Full-Time Employed

Part-Time Employed (less than 20 hours a week)

Part-Time Employed (more than 20 hours a week)

Casual/On Call

Unemployed

Would you be available to attend online and in-person (Northern BC) classes for full-time hours, Monday to Friday? *

Yes

Are you willing to complete 6 weeks of in-person/ work placement training in the Community Support field? *

Yes

Are you registered at Work BC? *

Yes

Are you able to do a TB test as required? *

Yes

If Yes, where is your Work BC centre located? *

Case Manager's Name *

Case Manager's Phone Number *

Case manager's email *

How did you hear about this program? *

Are you able to provide a Criminal Record Check before the start of the program? *

Yes

Emergency Contact (Full Name) *

Emergency Contact Number *

Relationship *

Upload proof of English Proficiency *

Upload Resume *

Upload Photo ID *

Consent *

Your personal information will be collected for determining your potential to participate in this project. If you have any questions about the collection of this personal information, please contact PICS Vancouver Office at 604-324-7733. This information is being collected by Progressive Intercultural Community Services Society under Freedom of Information and Protection of Privacy Act (FOIPPA), section 26." I accept to be added to the waiting list of applications, and understand that my application will be reviewed and assessed on a first come first served basis. I, authorize Progressive Intercultural Community Services Society (PICS), any other service providers, schools, and community agencies to disclose/exchange my personal information, including the usage of my photo and /or video in the following: (1) Information regarding my training, employment history, and needs. (2) Information regarding my progress and follow-up results. (3) Attendance at scheduled interviews and interventions at the above agencies. (4) Information regarding marketing of the program. The information disclosed/exchanged will be treated as confidential and will be used only by the agencies listed above in conjunction with your application for service. I agree to also receive marketing and promotional emails and newsletters from PICS regarding upcoming education and training programs. I hereby declare that the information provided is true and correct. I also understand that any willful dishonesty may render for refusal of this application or immediate termination of my application.