Participant Information Form

The information collected in this form will be used to determine your eligibility for the Youth Employment Strategy (YES) program and for subsequent evaluation and accountability purposes (Parts A , B and C only).

For Interns: when you are done filling out Part B below, please click print. All the required application forms must be sent by mail to the NRCan Project Manager.

Human Resources and Skills Development Canada (HRSDC), on behalf of the Government of Canada, is responsible for the evaluation of the YES program in order to ascertain how beneficial the programs are to YES participants. Your help in providing accurate information is essential for HRSDC to evaluate the program and conduct participant surveys to ensure that the YES programs meet your needs.

The information you provide is collected under the authority of Privacy Act and other applicable privacy laws. Completion of this form is voluntary; however, failure to do so may impact your chances of being considered for the YES program and will negatively impact the evaluation of the YES program by HRSDC. In order to conduct the evaluation activities, information from other sources (e.g. Canada Revenue Agency for income level) may be linked with this data.

The information you have provided for evaluation and accountability purposes will also be shared with Natural Resources Canada.

The information is administered in accordance with the Privacy Act and applicable privacy laws. You have the right to the protection of, and access to, your personal information. It will be retained by HRSDC in Personal Information Bank HRSDC PPU 450, entitled Evaluation and Data Development, and by Natural Resources Canada. Instructions for obtaining this information are outlined in the government publication entitled Info Source, a copy of which is located at all Human Resources Centres. Info Source is also available at http://infosource.gc.ca.

PART A. Project Information – To Be Completed by the Recipient

1. Name of Contribution Recipient

2. File Number

3.Participant’s Start Date
(YYYY-MM-DD)

4.Anticipated Finish Date
(YYYY-MM-DD)

PART B. Participant Information – To Be Completed by the Participant

5. Surname

6. Given Name and Initial

7. Permanent Address

8. City

9. Province/Territory

10. Postal Code

11. Telephone Number

- -

12. Cellphone Number

- -

13. Email Address

14. Are you currently in receipt of Employment Insurance? Yes No

15. Date of Birth (YYYY-MM-DD)

16. Employment Status at Start of Internship

Employed
Unemployed
Student

17. Residency Status

Canadian Citizen
Permanent Resident
Refugee under the Immigration and Refugee Protection Act
Other

18. Highest Level of Education Completed

Some post-secondary education but not university (including CEGEP)
University Bachelor's degree completed
Master's or PhD incomplete
Master's or PhD completed

PARTICIPANT DECLARATION

19. Do you meet all of the following eligibility criteria? Yes No

At the beginning of the Contribution Agreement you are:

Between 15 and 30 years of age (inclusive)
A post-secondary graduate
Out-of-school
A Canadian citizen, permanent resident, or person who has been granted refugee status in Canada (no work permits or student visas)
Legally entitled to work according to the relevant provincial legislation and regulations
Not in receipt of Employment Insurance (EI) benefits

Participant’s Signature _______________________________

Date (YYYY-MM-DD)

20. Have you previously participated in a Career Focus Internship of the Youth Employment Strategy (YES)?
Yes No

21. First Official Language English French

22. Language Spoken English French Both

23. Language Written English French Both

24. Language Preference English French

The Federal Government is committed to equity in employment. You are encouraged to complete the following voluntary questions and indicate if you are a member of any of these groups.

25. Gender Male Female

26. Member of a Visible Minority Yes No

27. Person with a Disability Yes No

28. Aboriginal Group

Registered on-reserve
Registered off-reserve
Non status
Métis
Inuit

Participant Consent to Release Information

I (name of participant), the undersigned, give my consent for

(Contribution Recipient) to release the information contained in this form regarding my participation in a YES program to NRCan and HRSDC. I acknowledge that the information is collected and administered in accordance with the Privacy Act and applicable privacy laws, and that it may be used to determine my eligibility for the YES program and provided to NRCan and HRSDC for the evaluation and accountability of the YES program.

Participant’s Signature __________________________

Date (YYYY-MM-DD)

PART C – To be Completed by Recipient after the Internship Termination

29. Participant Did Not Complete the Internship
Date of Early Termination (YYYY-MM-DD)

Reason

Did not follow through
Employed / Self-employed
Moved
Not active in labour force
Returned to school
Other Please Specify

30. Participant Completed the Internship
Date of Completion (YYYY-MM-DD)

Participant is now

Searching for employment
Making career decisions
Returned to school
Employed/Self-employed
Not employed

31. Project Co-ordinator/Recipient's Name

Project Co-ordinator/Recipient's Signature ____________________________________

Date (YYYY-MM-DD)