PERSONAL INFORMATION
Are you known by
Name: ______any other name?: ______
AddressWhileAttendingSchool: ______
Telephone: (home)______(message left)______
Date of Birth: ______Sex: (female) (male)
Social Insurance Number: ______
Marital Status: Single Married Common Law
Separated Divorced Widowed
Number of Dependents: ______
GOALS:
- Why have you come to this program? ______
- What is it you want to be able to do? ______
- Do you have a career goal? Yes No
If yes, what is it? ______
EDUCATION:
- What was the last grade in school that you completed? ______
- How old were you when you left school? ______
- Why did you leave school? ______
- What good experiences did you have in school? ______
- What not so good experiences did you have in school?______
- What subjects did you enjoy? ______
- What subjects did you find difficult? ______
- Did you receive any special help when you were in school (such as tutoring, resource room, and special classes)? Yes No
What kind of help did you receive?______
- Have you ever been told that you had a learning disability? Yes No
If yes, what kind of learning disability? ______
______
- Have you attended any other education or training programs since you left school?
If yes, please list them: ______
______
- Did you like these programs? Why or why not? ______
WORK HISTORY:
- Are you working now? Yes No Full-Time Part-Time
If yes, what kind of work are you doing? ______
- What jobs / volunteer work you have done in the past?
Job______Date Began______Date Left______
Reason for leaving ______
Job______Date Began______Date Left______
Reason for leaving ______
Job______Date Began______Date Left______
Reason for leaving ______
- What jobs did you enjoy doing the most? ______
- What jobs did you not like to do? ______
- What kind of work would you like to do in the future? ______
LANGUAGE:
- Which language did you most often speak when growing up? ______
- Which language do you most often speak now? ______
HEALTH:
- Do you have any health problems that may affect your learning? Yes No
- If yes, what are they? ______
- Are you on any medication that may affect your learning? Yes No
- If yes, what medication are you on? ______
- Do you have any vision problems? Yes No
- If yes, what are they? ______
- .Do you have any hearing problems? Yes No
- If yes, what are they? ______