Online Intake JVS Toronto – Online Intake Registration Form Please fill in the following information to register for JVS Toronto programs and services. A representative will contact you within 24 hours. Please note that at this time all JVS Toronto employees are working remotely, and as such the return call may come from an anonymous phone number. We look forward to connecting with you soon. First Name * Last Name * I am interested in the following Program Area(s). Please check all that apply * Employment Services Disability Services Assessments and Psychology Services OtherOther Gender * Female Male Non-Binary Other Prefer not to Disclose Gender Date of Birth Mailing Address * City * Postal Code * Email Address * Primary Phone Number * Secondary Phone Number Family Status Single Married/Common-Law Separated/Divorced Child (Under 16) Prefer not to Disclose First Language American Sign Language (ASL) Amharic Arabic Armenian Bengali Bulgarian Cantonese Chinese Croatian/Bosnian Czech Dari – Afghanistan Dutch English English (India) Farsi/Persian Filipino French Georgian German Greek Gujarati Hebrew Hindi Hungarian Italian Japanese Korean Kurdish Malayalam Mandarin Marathi/Konkani Mongolian Nepali/Nepalese Pashto/Pushtu Polish Portuguese Punjabi Pushtu Romanian Russian Serbian Sinhala Somali Spanish Swahili/Kiswahili Tagalog Tamil Thai (Siamese) Tigrinya/Eritea Turkish Twi Ukrainian Urdu Vietnamese Yiddish Yoruba Other Prefer not to Disclose Other Languages American Sign Language (ASL) Amharic Arabic Armenian Bengali Bulgarian Cantonese Chinese Croatian/Bosnian Czech Dari – Afghanistan Dutch English English (India) Farsi/Persian Filipino French Georgian German Greek Gujarati Hebrew Hindi Hungarian Italian Japanese Korean Kurdish Malayalam Mandarin Marathi/Konkani Mongolian Nepali/Nepalese Pashto/Pushtu Polish Portuguese Punjabi Pushtu Romanian Russian Serbian Sinhala Somali Spanish Swahili/Kiswahili Tagalog Tamil Thai (Siamese) Tigrinya/Eritea Turkish Twi Ukrainian Urdu Vietnamese Yiddish Yoruba Other Prefer not to Disclose English Language Proficiency Strong Satisfactory Needs Development Country of Origin Afghanistan Albania Algeria Argentina Armenia Australia Austria Bahrain Bangladesh Barbados Belgium Benin Bolivia Bosnia and Herzegovina Brazil Bulgaria Cambodia Cameroon Canada Chad Chile China Colombia Congo Croatia Cuba Czech Republic Ecuador Egypt El Salvador Ethiopia Former Soviet Union France Gabon Germany Ghana Greece Grenada Guinea Guyana Haiti Hong Kong Hungary India Iran Iraq Israel Italy Jamaica Japan Jordan Kenya Korea Korea, North Korea, South Kuwait Lebanon Libya Macedonia Mali Mauritius Mexico Moldova Morocco Namibia Nepal Niger Nigeria Oman Pakistan Philippines Poland Portugal Qatar Romania Russia Saudi Arabia Senegal Serbia and Montenegro Singapore Somalia South Africa Sri Lanka St. Lucia St. Vincent Sudan Syria Thailand Togo Trinidad and Tobago Tunisia Turkey Ukraine United Arab Emirates United Kingdom United States Venezuela Vietnam Yemen Zambia Zimbabwe Other Prefer not to Disclose Newcomer Arrival Date Citizenship Status * Canadian Citizen Permanent Resident Live-in Caregiver Convention Refugee Open Work Permit Refugee Claimant Intend to Land Family Class Sponsored Landed Immigrant Other Prefer not to Disclose Highest Level of Education Elementary (Up to Grade 6) Middle School (Grade 7-8) High School (Grade 9-12) Diploma High School (Grade 9-12) Diploma – Incomplete College Diploma College Diploma – Incomplete University Bachelor Degree University Bachelor Degree – Incomplete University Master’s Degree University Master’s Degree – Incomplete University Doctorate Degree University Doctorate Degree – Incomplete University Post Doctorate Degree Country Where Education was Attained Canada Other Country Where Education was Attained Primary Source of Income Employed Savings Spouse/Partner Parent/Guardian/Family CPP/Pension/RIFF LTD Shelter Allowance Training Allowance EI ODSP Severance WSIB Ontario Works SFAP Student Loan Other Prefer not to Disclose Primary Source of Income Reason for coming to JVS Career/Education Plan Language Training Use Resources (Computer/Internet, Fax, etc.) Counselling/Assessment Life Coaching Employment Plan Volunteer Experience Job Search Skills Training Work Experience Other Prefer not to Disclose How did you hear about JVS Another Jewish Organization Helping Professional (Doctor, Psychologist, etc) Media Promotional Materials Walk-In Community Agency Newspaper Advertisement Referred by Former/Current Participant JVS Website Government (Municipal, Provincial, Federal) Job Fair Word of Mouth Legal School Prefer not to Disclose Other How did you hear about JVS Name of Referrer Questions or Comments Informed Client Consent to Collect, Use and Disclose Personal Information Privacy of personal information is an important principle to JVS Toronto. We are committed to limiting the collection of information to what is necessary for the purposes identified by JVS Toronto to allow JVS Toronto to provide necessary services for a respective client. We also limit use and disclosure of personal information for purposes other than those for which it was collected. Personal information will only be collected by fair and lawful means and includes any factual or subjective information, recorded or not, about an identifiable individual, such as: age, name, income, opinions, evaluations, etc. JVS Toronto ensures that we will not disclose personal information to third parties without your consent, unless we are legally required to do so. JVS Toronto has a number of security safeguards in place to protect your information. * I acknowledge that I understand the purpose for which my personal information is being collected and I authorize the collection, use, storage and disclosure of my personal information by JVS Toronto. Canadian Anti-Spam Legislation Consent JVS Toronto requests your consent to send electronic messages about the agency (unrelated to your program/service) such as notices, announcements, events and fundraising activities. For more information on Canada’s anti-spam laws, visit www.fightspam.gc.ca. For JVS Toronto’s privacy policies, visit www.jvstoronto.org/privacy-policy. You can change your mind and withdraw your consent by contacting your JVS Toronto representative. * I consent to receive electronic messages using my email address on file. I do not consent to receiving electronic messages. Rules and Regulations JVS Toronto aims to provide a safe, inclusive and welcoming environment in which all individuals are treated with respect and dignity. Clients are expected to treat all individuals with respect including staff and other clients; any form of verbal abuse will not be tolerated. JVS Toronto staff has the discretion to give out warnings and/or revoke client privileges to access programs, services for not adhering. Signature * Clear Date Submit If you are human, leave this field blank.