First Name *

Last Name *

Phone Number *

Your Email *

Birthdate (mm/dd/yyyy) *

What city do you live in? *

Are you currently employed? * ---YesNo

If you are currently employed, do you work less than 20hrs per week? * ---YesNo

Are you currently enrolled in school? * ---YesNo

Are you legally permitted to work in Canada? * ---YesNo

If so, what is your status? * ---Canadian CitizenPermanent ResidentRefugeeWork PermitStudent PermitOther

How are your computer skills? * ---I could use some helpFairGood

Do you have a laptop or computer with microphone and camera capabilities? * ---YesNo

When are you most likely to be available* ---MorningAfternoonEither works

Could you commit 2-3 hours a day of video conference or class work? * ---YesNo

Which program are you interested in? * ---Virtual - Youth KamlooopsVirtual - Multi-barriered KamlooopsVirtual - Multi-barriered SecheltVirtual - Rise Program for Survivors of Violence and/or Abuse

Do you identify as having a disability or long-term health issue? * ---YesNoI'm not sure

Where did you hear about this program? *
FacebookInstagramOnline Search (e.g. Google)Info Booth (e.g. at Starbucks)Radio / TVNewspaperWorkBCBrochure / PosterJob FairOther: