Literacy Intake Form

Step 1 of 4

Education
Indicate your Highest Level of Education/Qualification:*
Institution of Highest Level of Education
Program Description
Start Date
Date Format: MM slash DD slash YYYY
End Date
Date Format: MM slash DD slash YYYY
Type
- Full-Time
- Part-Time
Country of Institution
Additional Education
- Some Apprenticeship
- Some College
- Some University
Institution of Additional Education
Program Description
Start Date
Date Format: MM slash DD slash YYYY
End Date
Date Format: MM slash DD slash YYYY
Type
- Full-Time
- Part-Time
Country of Institution

Employment List your most recent work experience.
Employment Type
Name of Employer
Job Title/Duties
Employment Start Date
Date Format: MM slash DD slash YYYY
Employment End Date (If Applicable)
Date Format: MM slash DD slash YYYY
Country of Enployment
Pay Period
Wage Amount ($)
Employment Hour Per Week
Reasons for Leaving (If Applicable)
Client Self-Assessment
How long do you think you will spend in the program (weeks)?*
On average, how many hours a week can you devote to your leaning in class?*
On average, how many hours a week can you devote to your leaning on your own time?*

Notice of Collection and Consent Your organization delivers Literacy and Basic Skills under an agreement with the Ministry of Labour, Training and Skills Development (Ministry) and is required to make its records available to the Ministry for inspection, investigation or audit. Your organization is also required to report to the Ministry on: • the service it tailors and provides you; • your employment progress and outcome; and • your satisfaction with the services you receive. The Ministry will also collect relevant personal information about you from the Government of Canada (Canada) if necessary. The purpose of this information is to determine your eligibility for Employment Insurance benefits, the nature and level of Employment Insurance benefits, and to monitor, assess and evaluate the effectiveness of Literacy and Basic Skills. Depending on the type of service or support you receive and any incentives available to your employer to hire you, your organization or the Ministry may also collect personal information about you from your employer. The Ministry may use contractors and auditors to administer and finance Literacy and Basic Skills. Administration includes: • Assessing the performance of your organization – its effectiveness, efficiency and customer service results; monitoring, inspecting, investigating, auditing and enforcing your organization’s compliance with its agreement with the Ministry. • Planning, evaluating and monitoring Literacy and Basic Skills – this includes conducting surveys, and conducting policy and statistical analysis and research related to all aspects of Literacy and Basic Skills. You may be contacted to request your voluntary participation in surveys. • Promoting Literacy and Basic Skills – you may be contacted to request your voluntary participation in public relations campaigns related to Literacy and Basic Skills. If you are a client of, or applying to, the Ontario Disability Support Program or Ontario Works, the Ministry will provide your personal information to the Ministry of Children, Community and Social Services (MCCSS) for the purposes of administering employment services and managing the participation of MCCSS clients in employment support programs under the Ontario Works Act, 1997, and the Ontario Disability Support Program Act, 1997. Literacy and Basic Skills is funded by the Ministry, in part with funds provided by Canada under Part II of the Employment Insurance Act. When funds are provided by Canada, the Ministry is required to provide information to Canada to help monitor and assess the Employment Insurance Program, as required under s.3 of the Employment Insurance Act. Under the Labour Market Development Agreement between Canada and Ontario (LMDA) and the Workforce Development Agreement between Canada and Ontario (WDA), the Ministry is required to collect your social insurance number. The Ministry collects your personal information pursuant to the LMDA and WDA, ss. 3 and 63 of the Employment Insurance Act, S.C. 1996, C.23 as amended, and s.76.29 of the Employment Insurance Regulations, SOR/96-332. The Ministry will collect personal information from clients who identify as Ontario Disability Support Program or Ontario Works recipients and disclose your personal information to MCCSS in accordance with the s.71 of the Ontario Works Act, 1997, and s.53 of the Ontario Disability Support Program Act, 1997. For more information about the collection and use of your personal information to administer and finance Literacy and Basic Skills, you can contact the Manager, Employment Ontario Call Centre, in writing at the Ministry of Labour, Training and Skills Development, 33 Bloor Street East, 2nd Floor, Toronto, Ontario M7A 2S3 or by phone at 1-800-387-5656. For the hearing impaired, TTY is available at 1-866-533-6339.
Participant's Name*
First Last
Participant Signature*
Date*
Date Format: MM slash DD slash YYYY
Parent/Guardian's Name*
First Last
Participant Signature (if applicant is under 16 years old)
Date*
Date Format: MM slash DD slash YYYY