Client Registration Form

You are on the VANSDA client registration page. The first step to your accessing our varied service offerings is to complete the form found here. We request that you fill out all the fields as completely as possible before you submit. Upon receiving your information, you will be contacted by one of our staff and advise you of the next steps. We hope this online registration meets your needs and allows us to provide you faster service. Should you require assistance in completion of the form or support services available please call 902 678-7410 ext.201

Javascript is disabled

Javascript is disabled on your browser. Please enable it in order to use this form.

Personal Information

Title*

Mr.

Mrs.

Ms.

Miss

Gender*

Male

Female

LGBTQ+

Prefer not to report

Date of Birth*

Last Name*

Enter Last Name

First Name*

Enter First Name

Initial

Enter Initial

Phone #*

Enter Phone Number

Mobile*

Enter Mobile Phone

Email Address*

Enter Email

Service Language*

English

French

Other Language

English

French

Mailing Address

Care of*

Enter Care Of

Province*

Enter Province

Home Mailing Address*

Enter Street Address

Country*

Enter Country

City / Town*

Add City or Town

Postal Code*

Enter Postal or Zip Code

Civic Address (if different than above)

Care of

Enter Care Of

Province

Enter Province

Home Mailing Address

Enter Street Address

Country

Enter Country

City / Town

Add City or Town

Postal Code

Enter Postal or Zip Code

Employment Information

Are you currently working ?*

Yes

Benefit Information

General Information

What language do you prefer to correspond in?*

English

French

What is your preferred correspondence method?*

Regular Post

Telephone

How many dependants do you have?

Enter dependants

What type(s) of driver's licence do do you have?*

No Licence

Beginners - Class 7

Motorcycle - Class 6

Regular Vehicle - Class 5

Small Bus / Taxi - Class 4

Heavy Vehicle - Class 3

Large Bus - Class 2

Tractor Trailer - Class 1

What is your residency status?

What is your residency status?*

Canadian Citizen

Permanent Resident

Other

Do you consider yourself to be a member of any designated groups?

Aboriginal*

Yes

Prefer not to report

Person with Disability*

Yes

Prefer not to report

Francophone / Acadian*

Yes

Prefer not to report

African Nova Scotia*

Yes

Prefer not to report

Immigrant*

Yes

Prefer not to report

If yes, Immigration Year

Enter Year

Visible Minority*

Yes

Prefer not to report

If you checked yes to any of the above, provide any additional details.

Please provide details here

Service Participation

Are you currently involved with other service organizations?*

Yes

Please list any community partner(s) you are currently or have recently worked with.

Enter names here

Is there anything else that may impact your ability to either attend or participate in meetings or group services / workshops?*

Yes

If yes, please explain:

Please explain here

How did you hear about us?

Please answer here.

Education History

Where did you receive your highest level of education?

Canada - Province

Enter school province here

United States - State

Enter school state here

Other Country

Enter school country here

Please provide your educational history below. Including courses or programs completed, stated but never finished, or currently in progress. Include post-secondary, trades, and other training courses taken.

Employment History

Jobs - Most Recent

COLLECTION, USE & DISCLOSURE OF PERSONAL INFORMATION

COLLECTION: The personal information you have provided is collected under the authority of the Nova Scotia Freedom of Information & Protection Act and the Employment Insurance Act of Canada and will be used only verification of service eligibility and administration of the applicable service.

USE: The personal information collected will only be used and disclosed in keeping with the access and privacy provisions of the Nova Scotia Freedom of Information and Protection of Privacy Act and the Nova Scotia Personal Information International Disclosure Protection Act. Uses may include: determining services appropriate to the needs of the client, determining eligibility for programs during an agreement funded by Employment Nova Scotia and to provide statistical information to agencies providing funding support to the services offered.

DISCLOSURE: The personal information provided may be shared with a service provider organization, service Canada, Employment Insurance, the Department of Community Services, Employment Nova Scotia and / or a training institution that is administering a program or service. This information may include: contact information, return to work action plan, eligibility for employment benefits, service eligibility, marks, attendance, and proof of financial payments to the training institution. The personal information provided may also be shared with other relevant departments within Government of Canada and the Canada Revenue Workforce Development Agreement.

ACCESS: Pursuant to the Nova Scotia Freedom of Information and Protection of Privacy Act individuals have the right to protection of, and access to, their personal information. To obtain access to, or request correction of, your personal information collected and used by VANSDA please contact the organization at info@vansda.ca or phone (902) 678-7410 ext. 201.

I acknowledge that I have read and understand the above information regarding the collection, use, and disclosure of my personal information:

I Accept & Understand

First Name*

Enter First Name

Last Name

Client Registration Form

Personal Information

Mailing Address

Civic Address (if different than above)

Employment Information

Benefit Information

General Information

What is your residency status?

Do you consider yourself to be a member of any designated groups?

Service Participation

Education History

Where did you receive your highest level of education?

Employment History

Jobs - Most Recent

COLLECTION, USE & DISCLOSURE OF PERSONAL INFORMATION

Your form has been submitted