Dixon Hall Literacy & Basic Skills Application Form
Please complete the following form to let us know a little about you and your background and to see if this is the right program for you.
The information collected in this form is used by Dixon Hall Neighbourhood Services, an Employment Ontario Service Provider, to capture participant information of individuals wishing to access the Literacy & Basic Skills (LBS) program. After the form is submitted successfully, a Dixon Hall team member will contact you by phone within 1-2 business days to complete the application. At that time you will be asked to provide your Social Insurance Number and any other requested information.
NAME
Legal first name *
Legal last name *
Middle Name
Preferred Name
Social Insurance Number (SIN)
ADDRESS
Unit/Suite/Apartment Number
Street Number *
Street Name *
City/Town *
Province *
Postal Code *
PO Box (if using one)
CONTACT INFORMATION
Primary Phone Number *
Alternate Phone
Email Address (If you do not have an email address write: application@dixonhall.org) *
Confirm Email Address *
STATUS
When were you born? *
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Were you born in Canada? *
I identify as *
Status in Canada *
Status in Canada if Other
Date Arrived In Canada (If Born Outside Canada)
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Marital Status *
SELF IDENTIFICATION, LANGUAGE, DEPENDENTS, AND INCOME
Self Identification
Are you a person with a disability
Are You A Member Of An Aboriginal Group?
Are you a racialized person?
Are you a newcomer to Canada? *
Are you deaf?
Are you deafblind?
Are you a Francophone Ontarian?
Dependents
How many dependents do you have? Dependents are spouse or children under 18 years old. *
Language
What language do you speak at home? *
What language did you speak at your last workplace? *
Preferred Language Of Service *
What is your preferred method of communication?
Income
What is your source of income ? *
EDUCATION TRAINING AND EMPLOYMENT HISTORY
Education
What is the highest level of education that you have completed? Only select the highest one that you completed. This includes education outside of Canada. *
Where did you complete this education? *
How long have you been out of Formal Education? This means how long ago did you complete high school, college or university? *
Do you have a history of interrupted education? That is, did you start school and stopped then started again or did not finish. *
Training
Referral - How did you hear about Dixon Hall Literacy & Basic Skills? *
Are you also enrolled in another Employment Ontario Literacy and Basic Skills training program? * *
If necessary, do you give Dixon Hall Literacy & Basic Skills permission, to share information about your learning with Other Service Providers? *
How Long Have You Been Out Of Training? That is , any training that was for 5 days or more . *
Employment
Labour Force Attachment - Which of these best describe your current employment situation? *
Employment Experience *
Are you a Registered Apprentice? *
How long have you been out of work? *
GOAL PATHS AND PREFERENCES
What Is Your Long Term Goal? *
Availability For Class
Select ALL the times that you will be available to attend class. *
Required
Which Training do you want to apply for? *
Comments (Please Enter Any Other Comments You May Have)
Notice of collection of personal information and consent (Ministry of Labour, Training and Skills Development)
Your Service Provider delivers the Literacy and Basic Skills Program under an agreement with the Ministry of Labour, Training & Skill Development (Ministry) and is required to make its books and records available to the Ministry for inspection, investigation or audit. Your Service Provider is also required to report to the Ministry on:
• The services it provides to you;
• Your education and training progress as well as your results when you finish the program; and
• Your satisfaction with the services you receive.

The Ministry will also collect relevant personal information about you from Canada if necessary to determine your eligibility for and the nature and level of Employment Insurance benefits and to monitor, assess and evaluate the effectiveness of the Literacy and Basic Skills Program.

The Ministry will use your personal information to administer and finance the Literacy and Basic Skills Program. For purposes of administering the Literacy and Basic Skills Program, client information collected on this form will be recorded, either by the Service Provider or Ministry, in the Ministry’s Employment Ontario Information System. The Employment Ontario Information System is used by the Service Provider and the Ministry to support the administration of Employment Ontario programs and services, including the Literacy and Basic Skills Program. The Ministry may use contractors and auditors to administer and finance the Literacy and Basic Skills Program.

Administration includes:
• Assessing the performance of your Service Provider – its effectiveness, efficiency and customer service results; monitoring,
inspecting, investigating, auditing and enforcing your Service Provider’s compliance with its agreement with the Ministry.
• Planning, evaluating and monitoring the Literacy and Basic Skills Program – this includes conducting surveys; and conducting
policy and statistical analysis and research related to all aspects of the Literacy and Basic Skills Program. You may be
contacted to request your voluntary participation in surveys.
• Promoting the Literacy and Basic Skills Program – you may be contacted to request your voluntary participation in public
relations campaigns related to the Literacy and Basic Skills Program.

The Literacy and Basic Skills Program is funded by the Ministry, in part with funds provided by Canada under Part II of the Employment Insurance Act. When funds are provided by Canada, the Ministry is required to help facilitate Canada’s monitoring and assessment of the Employment Insurance Program, as required under s.3 of the Employment Insurance Act. Under the Labour Market Development Agreement between Canada and Ontario (LMDA) and the Workforce Development Agreement between Canada and Ontario (WDA), the Ministry is required to collect your social insurance number.

The Ministry collects your personal information in accordance with s. 38(2) of the Freedom of Information and Protection of Privacy Act, R.S.O. 1990. C. F.31, as amended, and pursuant to the LMDA, ss. 3 and 63 of the Employment Insurance Act, S.C. 1996, C.23 as amended, s.76.29 of the Employment Insurance Regulations, SOR/96-332.

For more information about the collection and use of your personal information to administer and finance Literacy and Basic Skills Program, you can contact the Manager, Employment Ontario Call Centre, in writing at the Ministry of Training, Colleges and Universities, 33 Bloor Street East, 2nd Floor, Toronto ON M7A 2S3 or by phone at 1-800-387-5656. For the hearing impaired, TTY is available at 1-866-533-6339.

If you would like to discuss this directly with Dixon Hall some more, please email us at: esc.info@dixonhall.org
Registration Acknowledgment
By submitting this form, I acknowledge that the information on the forms is accurate, and that I read the understood the purpose for the Notice of Collection and Consent (as it is listed in the Employment Ontario Participant Registration). By submitting this form, I am expressing my signature to the terms and conditions of service as outlined in the documentation.By submitting this form, I acknowledge that Dixon Hall Literacy & Basic Skills Staff explained the use and disclosure of my personal information and its purposes.
Agree *
Required
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