R Work Group Application Form

“A year from now you may wish you had started today”

Services you're applying for: Select all that apply

Individualized job search supports

Online job search workshops (small group)

Resume development/creation

If you're interested in attending workshops, which workshops would be most beneficial? Check all that apply

Job Search Strategies

Resume Writing

Interview Skills

Workplace Communications and Conflict

Computer Skills

Addiction Recovery and Return-to-work

Exploring Your Career Path

First Name

As appears on S.I.N. document

Last Name

As appears on S.I.N. document

Previous names

We need the name linked with your S.I.N. in order to verify eligibility

Preferred name

Street Address

City

Postal Code

Birthdate - Month

Birthdate - Day

Birthdate - Year

Phone Number

Do you consent to receiving text messages about appointment reminders, upcoming workshops, follow-ups, etc.?

Yes

Can we advise those who may answer your phone of appointment reminders or requests for employment updates?

Yes

Are you currently employed?

Yes

Have you worked in the last year?

Yes

Estimated number of hours worked in the last 12 months:

If you are currently employed, are you: Select all that apply

Working fewer than 16 hours per week

Working more than 16 hours per week

At risk of losing your job

Underemployed

Not working in the field you're trained for, not getting enough hours

None of the above

Your employment status can effect your eligibility for our services. We will discuss the options available to you based on your current employment status.

Social Insurance Number

Please be aware that we will request your SIN as it's a requirement of the provincial and federal government for the workshops and individualized services. For security reasons, please DO NOT send your SIN via text or email. We will ask for the information over the phone, in-person, or in a private online video conference room.

For the workshops, you may contact the Contract and Procurement Specialist Yolanda Fowler at 780-538-5592 or yolanda.fowler@gov.ab.ca to confirm that this is required information if you wish.

Consent to Disclosure for Workshops and Individualized Services

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 databases 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.

ADDITIONAL WORKSHOP DISCLOSURE CONSENT: Thank you for applying to our Career Coaching Workshops funded by the Alberta Government. Because the costs for these workshop(s) are covered by the Alberta Government, we need to provide them with basic information on who our participants are and who attends the workshops, and this information is entered into their database (Mobius). By participating in these workshops, you are agreeing to us sharing some basic information with our funder for the purposes of program management and project monitoring.

Additionally, as some participants are requested to attend these workshops by Alberta Community and Social Services, you are agreeing to us advising them if you do or do not attend the workshops, whether or not you are employed or attending school, and general engagement in the sessions online.

Your signature indicates understanding and agreement for us to use your information in the manners stated above. By inserting the date below and submitting this form to us, you are indicating agreement and understanding of this consent. If you have any questions or concerns about how your data may be used, please contact Bonnie Maguffee (R Work Group Director) at 780-814-4172.

Do you give R Work Group permission to share the information on this form between their two programs? You may be eligible for workshops and individualized services, the information on this form can help determine eligibility for both programs.

Yes

Date field

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

Alberta Supports

Mental Health

Physician/Psychiatrist

Community Agency

Friend

Social Media or Website

AISH

Other

If you answered community agency or other, where did you hear about us?

Background Information

Year immigrated

If you are an immigrant, what year did you come to Canada?

Dependents

Number of people in your household under 18 who depend on you for support

If selected "Other", please identify:

If receiving E.I., estimate when benefits STARTED:

If receiving E.I., estimate when your benefits will END

ADDITIONAL CONTACT: It can be helpful if you provide a contact name and phone number of an individual that we can contact if, for some reason, we were unable to contact you (e.g., your phone is disconnected/no minutes). By providing a name and number of an additional contact person, you are agreeing that we can identify who we are and our services, and leave our contact information request. If you do not wish to do this, then leave the Additional Contact Name and Number blank.

Additional Contact Name

Phone Number

Online Informed Consent and Disclosure

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.

If, due to technology, an online session is interrupted, then RWG will contact you by your cell phone or email to confirm booking of the next session

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 inserting the date below and submitting this form, you are acknowledging your agreement to abide by our 'recordings' policy.

Date field

Thank you for applying. R Work Group will confirm receipt of your application via email within 3-5 business days. If you need immediate assistance or have any questions please call 780-539-1072.

Relevant Files ie. Resume/Cover Letter, requested documentation, etc.

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