Active Measures Application

Fill out the form below to the best of your knowledge. You can download a PDF version of this form here:

If you need assistance with filling out this form please contact Liz Robinson at 250-632-6151 ext 223

Active Measures Signup

First Name

Last Name

Gender

Male

Female

Address

Address Line

City

Province

Postal Code

How long have you been at this address?

Previous Address

Address Line

City

Province

Postal Code

Home Phone

Cell Phone

Birthdate

Email

Who were you referred by?

Do you have aboriginal ancestry?

Yes

No

Are you a Haisla Band Member?

Yes

No

Status Number

Dropdown

Do you have a drivers license?

Yes

No

Are you Currently Employed?

Yes

No

Are you in receipt of EI?

Yes

No

Have you received EI in the last 3 years?

Yes

No

Have you received Maternity or Paternity leave in the last 5 years?

Yes

No

Are you currently on BC Benefits? (SA)

Yes

No

How long have you been on SA?

How many dependents do you have living with you?

How many dependents do you have that do not live with you?

Do you require Childcare?

Yes

No

Education Information

Highest Grade Completed

Education

Dogwood Certificate

GED or Equivalent

College/University

What Program?

Completed?

Yes

No

Work History

Employer

Job Title

Length of Employment

Reason for leaving

Employer

Job Title

Length of Employment

Reason for leaving

What are the two biggest challenges you have faced in the last year?

What challenges or improvements have you made in the last six months?

How do you contribute to the community?

What are your fears about attending the life skills program?

What changes do you see are needed in your life?

What are your immediate goals for this program?

How would you contribute to this program?

How might you self-sabotage yourself in completing this program?

What are your strengths?

What are your weaknesses?

What are your abilities? (skills, talents, etc)

What do you want to focus on in this program?

In your own words, what are your presenting challenges?

	Yes	No
Do you have a current resume?
Can you provide an employer 3 references?
Have you attended any certification training within the last year?
Have you attended Active Measures previously?