First Name
*
Last Name
*
Full Address
*
Phone
*
Email
*
Date of birth
*
How did you hear about this project?
*
Facebook
Craiglist
LinkedIn
PICS Website
From a friend or colleague
Learned about it at a conference or event
Saw a poster or advertisement
WorkBC Centre
If you've selected 'WorkBC Centre', please mention the city
Gender
*
Male
Female
Non-binary
Prefer not to say
Do you self-identify as ( Select all that apply):
*
2SLGBTQI+
Woman
Indigenous person
Person with disability
Newcomer
South Asian
Chinese
Black
Filipino
Latin America
Arab
Southeast Asian
West Asian
Korean
Japanese
Visible minority not included elsewhere
Multiple visible minorities
Age Group :
*
18 - 30
31 - 50
51 - 65+
Are you currently living in British Columbia?
*
Yes
No
Legal Status in Canada
*
Citizen
Permanent Resident
Convention Refugee
If you have selected "Convention Refugee" please answer if you have received the Notice of Decision letter from the court?
Yes
No
Country of Origin
*
Year arrived in Canada (if applicable)
Do you consider yourself a member of a Francophone Official Language Minority Community, meaning a French speaker living outside of Quebec?
*
Yes
No
What is your total household income?
*
$0 to $19,999
$20,000 to $29,999
$30,000 to $39,999
$40,000 to $49,999
$50,000 to $59,999
$60,000 to $69,999
$70,000 to $79,999
$80,000 to $89,999
$90,000 to $99,999
$100,000 to $149,999
$150,000 and over
Prefer not to answer
Employment Status
*
Full time
Part time (less than 20 hours per week)
Part time (more than 20 hours per week
Student
Casual/ On Call
Unemployed
Education Level
*
High School
College
University
Other
Do you have any additional certifications or relevant training?
*
Yes
No
If yes, please write details:
Which of the following sectors would you be interested in for further training/employment after completing this project?
*
Retail
Hospitality
Construction
Financial Services
Other
Emergency Contact (Full Name)
*
Emergency Contact Number
*
Relationship
*
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 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." 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
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