Full Name *

Phone *

Email *

Date of birth *

Address

Street Address

City

State

Country

Postal code

Are you a Canadian Citizen? *

Yes

No

Do you self-identify as Indigenous Person (First Nations, Métis, or Inuit)? *

Yes

No

If yes, pick one:

First nation

Metit

Inuit

Other

Employment Status *

What is your highest level of education? *

Completed Grade 10

Completed Post Secondary

Completed College/university

Other

Are you receiving any financial support? *

EI (Active Employment Insurance)

BCEA PWD

BCEA Non-PWD ((Income Assistance/ Welfare)

None of the above

Would you be available to attend in-person classes in Surrey for full-time hours from 9am – 5pm, Monday to Friday? *

Yes

No

Are you 18 years and above?

Yes

No

Emergency Contact (Full Name) *

Emergency Contact Number *

Relationship *

How did you hear about this program? *

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 or surrey office 604-596-7722. This information is being collected by Progressive Intercultural Community Services Society under Freedom of Information and Protection of Privacy Act (FOIPPA), section 26.&quot; 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.