CLIENT INTAKE

Request for Employment Services

Please complete the form below to request employment services from Regina Work Preparation Centre.

Secure formYour submitted information is stored in an encrypted request file and is accessible only to authorized staff.

Client Information

* Last Name * First Name * Phone # * Email * Preferred Method Contact * Date of Birth * Address Gender Pronouns

Indigenous Group Indigenous Non Status Metis Inuit Treaty/Registered (Status) Non Indigenous Prefer not to respond

Citizenship & Immigration Permit Expiry Date

ICT#

* Are you legally entitled to work in Canada? Yes No I do not know

CLB Assessment Yes No

Date SpeakingReadingListeningWriting

Past client of Regina Work Preparation Centre?

Employment Status Unemployed Employed Self Employed Actively Job Searching

Current Level of Education Grade completedPost Secondary Type

Disability Visible Minority Self-declared Mental Health Issues

How did you hear about our services?

Check all that are of interest to you.

Employment Pathways Digital Literacy Job Launch Virtual Reality (VR) In Motion, Momentum, & Momentum+ Client ID #

I have read and agree to the consent above.

* Client Signature (type full name)* Date