Launch Application Form

Name *

First

Last

Date of Birth *

Phone Number *

Address *

Email *

Emergency Contact *

First

Last

Relationship *

Phone Number *

Email

Caseworker Information (If Applicable)

First

Last

Agency

Phone

Fax

Email

Are you between the ages of 15 and 30? *

• Yes
• No

Are you a Canadian citizen, permanent resident, or person who has been granted refugee status in Canada? *

• Yes
• No

Are you out of school? *

• Yes
• No

Are you legally allowed to work in Nova Scotia? *

• Yes
• No

Are you currently unemployed or underemployed? (Working less than 20hrs/week) *

• Yes
• No

Have you received employment insurance benefits in the past 5 years, (or 5 years in the case of maternity leave)? *

• Yes
• No

Are you able to commit to 30 hours a week at minimum wage for the duration of the program? (Please note that childcare and transportation are not provided by the Launch Program) *

• Yes
• No

Do you have past work experience? *

• Yes
• No

Job One

Company

Position

Start Date

End Date

Duties

Job Two

Company

Position

Start Date

End Date

Duties

Job Three

Company

Position

Start Date

End Date

Duties

Why do you want to participate in the Launch Program? *

How will the Launch Program help you achieve your goals? *

What do you expect to learn from participating in the Launch Program? *

What do you hope to do after completing the Launch Program? *

• I confirm that the information given in this form is true, complete, and accurate

Phone

Submit