Youth Job Connection Referral Form

* Required

Referral Type

* Select the type of referral required:

Referral to Youth Job Connection
For individuals between the ages of 15 to 29, unemployed, not in full-time training or education

Referral to Youth Job Connection - Summer
For individuals between the ages of 15 and 18, students intending to stay in or return to school (secondary or post-secondary)



Client Contact Information

* First Name:

* Last Name:

* Date of Birth:
MM/DD/YYYY

* Phone:

* Email:

Do you have a SIN number?

Yes

No

Do you have a bank account?

Yes

No

Referral Information

Self Referral
  Same contact info as above

Agency Name:

Agency Phone:

Extension:

Contact Person:

Contact Person's Email:

Consent for Release of Information

In an effort to coordinate services, I hereby authorize the above-named service provider organizations to share and/or release any applicable information pertaining to my participation in services.

I acknowledge that the referring service provider may be notified once I have made contact with the referred service organization. I understand that I may, in writing, change or cancel this authorization at any time, except for such action as has already been taken.

As it pertains to Referrals from Ontario Works, MFIPPA applies:

I acknowledge that my personal information may be shared with various program participants as contemplated by s.14(1)(a) of the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, CHAPTER m.56; I understand that the treatment, storage and handling of my personal information is governed by the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990, CHAPTER m.56.

  By checking this box, the referred person has agreed to the Consent of Release of Information.

Disclaimer

Lambton College Community Employment Services ensures that your privacy will be protected by following the Personal Information Protection and Electronic Documents Act(PIPEDA). Information is collected, used and disclosed for the purpose of employment/training/service coordination to ensure your academic/employment goals are met. If at any time you have any questions/concerns or complaints related to Lambton College privacy policy and the treatment of your personal information please contact 519-542-7751 ext.3537.

Community Employment Services

Youth Job Connection Referral Form

Community Employment Services

Referral Type

Client Contact Information

Referral Information

Consent for Release of Information

As it pertains to Referrals from Ontario Works, MFIPPA applies:

Disclaimer