01 ISR - Application Form

The right job at the right time

Text: 780-876-7055

Telephone: 780-539-1072

First Name and Initial

As appears with S.I.N

Last Name

As appears with S.I.N.

Previous Names

we need the name linked with your S.I.N. to verify eligibility

Preferred Name

Address - Number and Street

City

Postal Code

Birthdate

Phone Number

May we text you to reschedule missed appointments, send appointment reminders, and follow-up with you?

Yes

If employed, how many hours do you work weekly?

Please give an average estimate of hours

Estimated number of hours work in last 12 months

Enter 0 if you have not worked any hours

If receiving E.I. estimate when benefits started

Estimate when EI benefits will end

How did you learn about us? (check all that apply)

Alberta Supports

AISH

Mental Health

Physician/Psychiatrist

Social Media

Friend/word-of-mouth

Other

If selected "other" please identify

Year immigrated

Province where highest level of education was completed

Year highest level of education completed

Secondary Contact Name

Secondary contact Phone Number

Declaration/Consent
The personal information provided to R. Work Group is collected, used, and disclosed under the authority of sections 33 to 40 of the Freedom of Information and Protection of Privacy Act. If you have questions about the collection or use of your personal information, please contact Bonnie Maguffee, R. Work Group Director at 780-814-4172 . Please read the privacy guidelines below carefully. Your signature indicates agreement to use of this information.

Our programs are federally and provincially funded and you may be eligible for one or both programs. For this reason we ask for your permission to share the information we gather with both provincial and federal funders. We use this information for program planning and for individual service planning. We may enter this information into the Service Canada or Mobius client database as they are the funders of the services you have applied for and this information is used for determination of participant eligibility and program planning. Your signature indicates understanding and agreement for use to use your information in this manner. By inserting the date below and submitting this form to us, you are indicating agreement and understanding of this consent.

Date (serves as your signature)

Online Informed Consent

1. Online vocational rehabilitation and career coaching services has both benefits and risks, which you and RWG will be monitoring as you proceed with your work.

2. You will need to participate in creating an appropriate space for your online vocational rehabilitation and career coaching services sessions.

3. RWG follows security best practices and legal standards in order to protect your health care information, but you will also need to participate in maintaining your own security and privacy

OUR COMMUNICATION PLAN

The best way to contact RWG between sessions is by calling 780-539-1072, Monday to Friday, 10 am to Noon, and 1 pm to 4 pm.
RWG will respond to your messages within 24 business hours. Please note that RWG may not respond at all on weekends or holidays.

RECORDINGS

By signing this form, you are agreeing to NOT record video or audio sessions. Making recordings can quickly and easily compromise your privacy, and we request that this not be done.

R. Work Group WILL NOT record video or audio sessions.
I understand and agree to the risks and benefits of online delivery of services by R. Work Group.

By 'dating' the form below and submitting to us, you are indicating agreement and understanding of our recordings policy.

Date (serves as your signature)

File attachments

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