Build Your Future Program - Referral/Application Form

The Build Your Future Program is a youth employment service that supports Surrey's at-risk youth to achieve employment

Eligibility Requirements:

16-30 years old
Legally able to work in Canada
Must live in the lower mainland of Vancouver
Must have Government Photo ID and SIN
Unemployed or previously employed
Have not participated in another program funded by Access BladeRunners
Able to attend each class in person

.

Form Type

Program Code

Participant Information

Preferred Name

First Name

Last Name

Legal Name

First Name

Middle Name

Last Name

Contact Information

Primary Phone Number

Alternate Phone Number

Email Address

Home Address

Street 1

Street 2

City

Province

Postal Code

Alternate Address

Street 1

Street 2

City

Province

Postal Code

Basic Information

Date of Birth

Pronoun(s)

Citizenship Status

Social Insurance Number

Gender

Ethnicity

What language do you need support with?

Emergency Contact

Emergency Contact Name

Emergency Contact Relationship:

Emergency Contact Number

Emergency Contact Email

Education

Name Of School

Level Completed

Special Needs

Any Special Needs/Preferences That We Should Know About?

Any Health Issues/Conditions/Allergies, Past Or Present That We Should BE Aware Of?

Are There Any Diagnosed Learning Disabilities?

YESNoNot Sure

If yes, please specify

Current or Previous Employment/Volunteer Experience

Are you legally Entitled to Work in Canada?

YESNO

Name Of Current or Last Employer

Start Date

End Date

Reason For Leaving

Do you consent to PCRS staff contacting this employer?

What are the applicant’s goals in relation to the service you are referring them to?

Goal 1

Goal 2

Additional Information and Documents

How Did You Hear About Build Your Future Program?