EMPLOYMENT REFERRAL FORM

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At PCRS, we want to support and work with you. Whether you are looking for a new job, a new home, or an education, our staff are here to help.

We provide employment services to job seekers and employers in various communities to help participants prepare for employment, secure and maintain jobs, and gain meaningful work experience. Employment is a key component to quality of life. We believe that every person has the capacity and potential to be successful given the right support.

To apply for support in any of this area please continue to the next page. The following application will ask for some basic information. After you submit this form, you can expect that someone from our team will reach out to you with next steps.

Which region would you like to participate in our services with?

Which program are you interested in?

Form Type

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Youth Information

Name

Chosen First Name

Chosen Last Name

Legal First Name

Middle Name

Legal Last Name

Basic Information

Date of Birth

Gender

Pronoun(s)

Ethnicity

If Indigenous, please specify

First Nations Band (if applicable)

Other Ethnicity

Contact Information

Home Address

Street 1

Street 2

City

Province

Postal Code

Email and Phone Number

Primary Phone Number

Alternative Phone Number

Email

Preferred Method of Contact

Emergency Contact Information

Emergency Contact Name

Relationship to Participant

Emergency Contact Phone Number

Emergency Contact Email

Related Contact (Select and add all that apply)

Related Contact Type

Related Contact Name

Related Contact Phone Number

Related Contact Email

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Participant Medical Information

Medical Information (if applicable)

Baristas and This Way ONward Eligibility

Education

Name of School

Level of Education Completed

Are There Any Diagnosed Learning Disabilities

If Yes, What are the Diagnoses?

Volunteer/Work Experience

Name of Last Employer

Start Date

End Date

Are You Eligible to Work in Canada

Duties

Reason for Leaving

Resume Attached

Cover Letter Attached

Job Options Eligibility

Are you Unemployed?

If Yes, Are You Underemployed?

Citizenship Status

Year Arrived in Canada

Are You Legally Able to Work in Canada

Looking For Work or a Career Change

Participating in Another Program

Access to a Computer

Are You Receiving EI or CERB

Have You Received EI in the Last 3 Years

Are You Currently on Any Pension Plan

Are You at Least 17 Years Old

Are You a Student

Are You a Resident of British Columbia

Level of English Proficiency

Do You Have Access to Reliable Internet

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Referral Information

Source of Referral

Reason For Referral

Referrer Name

Referrer Agency

Referrer Phone Number

Referrer Email

Relationship to Participant

YesNo

Is this referrer the participant's primary professional support

Comments (if applicable)