Participant Intake and Referral Form

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Note: Fields marked with an asterisk [*] are required.

Participant Information

First Name *

Last Name *

Street Address *

Suite/Unit Number

City/Town *

Province *

Postal Code *

Telephone * Best way to contact

Email * Best way to contact

Age Range or Birthdate *

Best Time to Contact

Morning Afternoon Evening

Do you identify yourself with any of the following? (Check all that apply) *

Woman Youth Urban Aboriginal Racialized Newcomer Veteran

Current Employment Status *

Full-time Part-time Unemployed Under-employed

Income fluctuation/rise or fall in the last 12 months

A great deal A lot Some A little Not at all

Job Objective *

What assistance are you seeking today from TCBN? How can we assist you? *

Mentoring, coaching and professional development Resume, interview and test preparation Help to obtain and organize necessary documentation for your chosen career Tips and resources on how to finance your work search Connecting you to apprenticeships and professional, administrative and technical jobs in the construction industry Other:

Eligibility Criteria (Check all that apply)

International Student Not in Employment, Education or Training Working 20 hours or less Underemployed or In Precarious Employment Ontario Works Employment Insurance Youth 17 to 29 year old Black Newcomer Indigenous Woman Canadian Citizen Permanent Resident Conventional Refugee Refugee Claimant with 1year open work permit Basic English language skills

Referring Agency or Referring Individual Information (check all that apply) *

I was referred by a staff of an organization

Org Name:

I was referred by a family member or friend

Person Name:

I was referred by other source

Other Referral Source:

Referral Consent

I hereby consent to the exchange of my personal information between the organization that I have been referred from and/or are working with, or will be referred to for the purpose of supporting, tracking, and reporting on my participation in the Community Benefits Program which includes the provision of employment and training needs assessments, social supports, skills training, and employment and retention services. I also consent to the collection, storage and reporting of information related to my demographic profile, participation in activities and events, employment status, the outcomes of employment interview(s) and subsequent employment related information, if applicable, related to the Community Benefits Program, or other referral I may receive from TCBN. I understand information collection may take the form of surveys, personal meetings, phone calls with me or my employer, text messages, and/or training forums. I understand that this information will be stored and transferred between electronic data systems with restricted access to Toronto Community Benefits Network staff, and may be used in aggregate form for reporting purposes. My information may also be used by the Community Benefits Program staff to recommend other employment services and make related referrals. I understand that this consent remains valid unless I withdraw it. I also understand that I can withdraw my consent at any time by giving notice in writing to any TCBN staff. I have read, or had read to me and understand the purpose of this consent set out above and give it voluntarily. By signing this form, I agree that by using the Community Benefits Program I expressly and affirmatively consent to the use and disclosure of the information that I provide, and consent to receive e-mails, phone calls or text messages in relation to the delivery of the Community Benefits Program.

Participant Name (First, Last)

Participant Signature

Date (yyyy-mm-dd)