Workshop Participant Form

Personal Information

Title*

Mr.

Mrs.

Ms.

Miss

Gender*

Male

Female

Other / X

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

What is your employment status?*

Employed

Self-Employed

Unemployed

What are your employment details?

Full Time

Part Time

Seasonal

Variable Hours

How many hours do you usually work per week in your current employment?*

Enter weekly hours

How much are you earning in your current employment?*

Per Hour

Do you have an expected layoff date?

Add date here

Have you been employed with gross insurable earnings of $2,000 or higher in at least 5 of the previous 10 years?*

Yes

No

Unknown

Are ytou part of a sector that is in transition or being impacted by a layoff?*

Yes

No

If yes, indicate sector:

Enter location

Have you applied for or had a regular, sickness or compassionate care El claim end within the last 60 months?*

Yes

No

Unknown

Have you had a maternity or parental claim that started in the last 60 months?*

Yes

No

Unkonwn

Are you legally entitled to work in Canada?*

Yes

No

Unknown

Are you currently involved with another agency?*

Yes

No

Unknown

What language do you wish to correspond in?*

English

French

What is your preferred correspondence method?*

Email

Telephone

Regular Post

How did you hear about us?

Please answer here.

Name of organization who referred you to us (if here by referral)

Contact Name

Enter name here

Contact Number

Enter number here

Case Information

What is your residency status?*

Canadian Citizen

Permanent Resident

Other

Do you have access to transportation?*

Yes

No

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 Trailor – Class 1

Are you willing to relocate to find work?*

Yes

No

If yes, where?

Write Here

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

Aboriginal*

Yes

No

Prefer not to report

Person with Disability*

Yes

No

Prefer not to report

Francophone / Acadian*

Yes

No

Prefer not to report

African Nova Scotia*

Yes

No

Prefer not to report

Visible Minority*

Yes

No

Prefer not to report

Immigrant*

Yes

No

Prefer not to report

If you checked any of the above, provide any additional details:

Write Here

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

Yes

No

If yes, please explain:

Write Here

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 NS Labour and Advanced Education please contact the department’s Information Access and Privacy Manager by email LAEaccess@gov.ns.ca or phone (902) 424-8472.

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

Email Address

Workshop Participant Form

Personal Information

Mailing Address

Civic Address (if different than above)

Employment Information

Name of organization who referred you to us (if here by referral)

Case Information

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

COLLECTION, USE & DISCLOSURE OF PERSONAL INFORMATION

Your form has been submitted