360°kids Employment Programs Referral/Participant Application Form

Please indicate which 360°kids Employment Program(s) this referral is for:

B4S Base 4 Success Learn More
STEP Specialized Training Employment Program Learn More
YSS Youth Success Strategy Learn More
SSW Supporting Students to Work Learn More
Unknown

Please Select

Participant is applying directly
Participant is being referred by a community agency

Agency Support Details (If Applicable):

Agency Name:

Name of Referrer:

Email:

Phone:

Participant Information:

Participant Name:

Preferred Pronouns:

Email:

Age:

DOB:

mm/dd/yyyy

Address:

City and Postal Code:

Cell Phone:

Please provide us with the following information:

Participant is between the ages of 15 and 30:

Yes
No

Participant is legally eligible to work in Canada:

Yes
No

Participant residency status:

Participant residency status (Other)

Participant has a valid Social Insurance Number (SIN):

Yes
No

Participant has been in another employment preparedness program in the last 3 years:

Yes
No

If yes, was it with 360°kids?

Yes
No

Participant has received any of the following government assistance:

EI
ODSP
OW

Participant is currently working:

Yes
No

If yes, is the employment:

FT
PT
Temp
Casual
Sporadic
Relief
Seasonal

Participant is currently enrolled in school:

Yes
No

If yes, what is the highest level of education:

Secondary
Post-secondary
Full-time
Part-time

If no, what is the highest level of education:

Participant is currently accessing 360°kids services:

Yes
No

If yes, which programs? (i.e. Connections, Home Base, Counselling)

If no, has participant accessed other 360°kids services over the past 2 years?

Yes
No

If yes, which programs? (i.e. Connections, Home Base, Counselling)

Does the participant have access to a:

Laptop/computer
Smart phone
Tablet
Wifi

Please CHECK ALL that apply and provide an explanation below, please note that these will not negatively impact your eligibility for the programs:

Does the participant have an IEP or accommodations in school that we should know about in order to best support?

Yes
No

Please provide any information that would help us support the participant through the duration of the program (i.e. current living/working situation, childcare, transportation, counselling, etc.) and why the 360°kids employment program may be a good fit (please type/write in the space provided)

Would the participant benefit from any accommodations to ensure success in a classroom and/or work environment? If yes, please type/write in the space provided.

Yes
No
Not disclosed

Accommodations to ensure success in a classroom and/or work environment:

Where did you hear about our programs?

A member of the 360°kids employment team will reach out to the participant directly within 3 business days of receiving your referral.
Thank you.