Dryden Urban Indigenous Homeward Bound Program

Application Instructions

Step 1. Program

Step 2. Program applicant has Professional Reference complete the Reference Form - the Referring Professional can be a previous employer, teacher, social worker, religious leader

etc. but not a friend or family member. (green forms)

Step 3. Program applicant completes the "Consent to Release Information" form. (pink forms)

Step 4. Program applicant submits the application, referral form and consent to release form to the Homeward Bound Program at Dryden Native Friendship Centre

Step 5. Applicant attend Pre-Screening interview and if all criteria are met, attend the formal interview

Eligibility Criteria:

Urban Indigenous woman (living in the Dryden area) Single, 19 years or older At least one child 17 or under and living with her English fluency (reading, writing and speaking) High school diploma or equivalent or Mature Student Assessment completed through Confederation College Able to enter college-level academics within 6 - 8 months Unemployed or underemployed No current criminal proceedings Able to commit to participating in a full time, 4-year program Professional reference

*If you are missing any of the above eligibility criteria, please speak with the Homeward Bound staff to discuss how to become eligible.

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Dryden Urban Indigenous Homeward Bound Program

Participant Application Checklist

• Professional Reference

• Completed application form

• Criminal Records Check & vulnerable sector screening completed

• Consent to release information form completed

• Submit all paperwork to Homeward Bound Staff

DRYDEN URBAN INDIGENOUS HOMEWARD BOUND PROGRAM

Application for Admission

PERSONAL INFORMATION:

First Name:------------ - ------- ------ ---

LastName: ------------- - - ----- ---------

Date of Birth- Month: ______ Day: _ _ _ ___ Year: ______ _

Marital Status - Single: Divorced: Separated:

Common law Married: Other:

First Language:

Social Insurance Number (SIN):

Current Address:

Do you: own rent subsidized rent Other (specify)

Phone: Cell Home - ---- ------- ---------------

Email address:

Do you identify as - FN Status: _ _ _ FN Non-Status: _ _ _ _ Metis Registered: _ _ _ Inuit: Self-Identified: Metis: ----

Current Source of Income - Employment: ____ _ Employment Insurance: ___ _ Support Program (ODSP) ____ _ Ontario Works ------Other (specify)

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DRYDEN URBAN INDIGENOUS HOMEWARD BOUND PROGRAM

DEPENDENTS:

Do you have legal custody of your children - Yes: __ No:

Number of Children: Number of Children living with you: ________ _

Child 1:

Name: Gender: ------------------ ---------

Date of Birth: Current Grade Level: ------------- ---------

Daycare- 0-6: _ ________________ _ After School: ---------- --

Special Needs- Yes: _____ No: ____ _

lf yes, please specify: --------------- ---

Child 2:

Name: Gender: - ---- ------------ ----------

Date of Birth: ___ ________ __ Current Grade Level: ____ _______ _

Daycare - 0-6: ______________ _ After School: ------------

Special Needs - Yes: _____ No: _____ _

If yes, please specify: _________________ _

Child 3:

Name: Gender: ------------------ ---------

Date of Birth: Current Grade Level: ---------------- ------- ---

Daycare - 0-6: ___________ _ After School: __________ _

Special Needs- Yes: _____ No: _____ _

lfyes, please specify: ------- - - ------------

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DRYDEN URBAN INDIGENOUS HOMEWARD BOUND PROGRAM

Child 4:

Name: ---------------------------------- Gender: _ ______________ __

Date of Birth: Current Grade Level: --------------------- -----------------

Daycare- 0-6: ____________________ _ After School: ___________________ _

Special Needs - Yes: ______ No: ________ _

If yes, please specify: - --------------------------- ---

Child 5:

Name: Gender: -------------------------------- ----------------

Date of Birth: ___________________ _ Current Grade Level: ____________ __

Daycare- 0-6: _ ________________ _ After School: ___________________ _

Special Needs - Yes: _____ No: _______ _

If yes, please specify: - ----- -----------------------

Comments on any special supports needed for children (medical, academic, behavioural counselling etc.)

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DRYDEN URBAN INDIGENOUS HOMEWARD BOUND PROGRAM

Other Family:

Do you have additional family members living with you? Yes: _____ No: _ __ _

If yes, please complete the following:

#1:

Name of Family Member: _ _ _____________________ _

Age: ________ Relationship to you: _ _ _ _ _ _ ___ _____ _

Do you financially support this family member: _ _ _ _ _ _____ _ _ ___ _

#2:

Name of Family Member: _ __________ ________ ____ _

Age: _____ __ Relationship to you: _______________ _

Do you financially support this family member: _ ______________ _

#3:

Name of Family Member:

Age: ______ __ Relationship to you: _____ _ _ ___ _ _ ___ _

Do you financially support this family member: _ ______ _____ ___ _

#4:

Name of Family Member: _ _ _ ______________ ______ _

Age: ________ Relationship to you: _ ______ _ _ _____ _ _

Do you financially support this family member:

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DRYDEN URBAN INDIGENOUS HOMEWARD BOUND PROGRAM

EDUCATION:

NruneofSchoolattended: -----------------------------------------------

Diploma or equivalent: _______________________ Date: ____________ _

How many years have you been out of school? ------------------------------

What areas do you believe require the most upgrading?

_____ Math ____ English ____ Reading

_ ___ Computers ____ Writing

Other (specify): --- -----------------------

Please rate your computer skills. 1 is not at all and 10 is quite extensive. Please circle,

Word 1 2 3 4 5 6 7 8 9 10 Excel 1 2 3 4 5 6 7 8 9 10 Power Point 1 2 3 4 5 6 7 8 9 10 Access 1 2 3 4 5 6 7 8 9 10 Outlook 1 2 3 4 5 6 7 8 9 10 Internet 1 2 3 4 5 6 7 8 9 10

Please describe any additional skills training that you have completed (i.e. computer classes, smart serve, food handling, music classes, driver' s licence, apprenticeships etc.)

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DRYDEN URBAN INDIGENOUS HOMEWARD BOUND PROGRAM

Describe your greatest concern about the transition back to school and/or work? What do you think will be your greatest challenge?

EMPLOYMENT HISTORY:

Are you currently employed? Yes: __ No _ _

If yes, who is your current employer?

Is your position- full time: ___ _ part time: ___ _

If unemployed, who was your last employer?

Job Title: ------------------------------

Last day worked: Year: ________ Month: ____________ _

Reason for leaving: Quit: _ __ Fired: ___ other (specify) : _________ _

Comments: ------------------------------

Please check any of the following skills/abilities you feel that you possess: ___ Good time- keeping Enjoy learning ___ Team Player Multi tasking ___ Independent Thinker Clear speaker

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DRYDEN URBAN INDIGENOUS HOMEWARD BOUND PROGRAM

Flexible Goal oriented - -- ---___ Hard Working ___ Good planner

Communication Skills --- _ __ Organized Professionalism ---

Please provide one example:

GENERAL INFORMATION:

What do you think will be your greatest challenge in returning to work/school?

Please check any of the following that you think may be barriers to your employment:

Medical/Health problems Employment record English Education Attendance/Punctuality Transportation Grooming Legal Emotional Housing Interpersonal Skills Day care/child care Literacy Substance use Anger Management Motivation Discrimination Other Math

Comments:

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DRYDEN URBAN INDIGENOUS HOMEWARD BOUND PROGRAM

Please describe your interest in the Dryden Urban Indigenous Homeward Bound Program and how you will sustain your commitment to the 4-year program.

If accepted into the Dryden Urban Indigenous Homeward Bound Program, what other supports do you think you may require?

Name of referring professional: -----------------------

Emergency Contact Information -Name of contact:

Phone number of contact: --------------

Relationship to contact:

Applicant signature:

Date: ------------ ---------------------

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DRYDEN URBAN INDIGENOUS HOMEWARD BOUND PROGRAM

Office use only:

Date application received: ___________ _

Application number: DUIHB -----------

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Dryden Urban Indigenous Homeward Bound Program

Reference Form *to be completed by Professional Reference

Program applicant name: -------------------------

Professional Reference: ---------------------------

Organization/business: --------------------------

Phone: ---------------- ext. _________ _ Fax: ___________ _

Email: -------------------

How long have you known the program applicant?

Overview of applicant's suitability for the Dryden Urban Indigenous Homeward Bound Program (must be completed):

Please complete the following as fully as possible. More information will assist us in ensuring that the applicant is the right fit for the program.

Interest in continuing education:

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Dryden Urban Indigenous Homeward Bound Program

Stren~hs: ----------------------------------------------------------

Commitment to a 4-year program: -------------------------------------------

Level of cooperation with others and staff: --------------------------------------

Conflict resolution skills: --------------------------------------------------

Stress Management: -----------------------------------------------------

Money Management:

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Dryden Urban Indigenous Homeward Bound Program

Do you have any concerns or issues that we need to be aware of which would impact their ability

to complete this program? -------------------------

Professional Reference Signature: ----------------------

Date: --------------------------------

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Dryden Urban Indigenous Homeward Bound Program

Release of Information

I, , hereby grant permission to the Dryden Urban Indigenous Homeward Bound Program to share my information for the purpose of assisting me in obtaining the necessary supports required to be successful in the application and completion of the Homeward Bound Program. I understand that the information shared will only be what is needed to obtain and provide support. Supports include but are not limited to: housing, childcare, transportation, career counselling, education, health and wellness, and cultural.

The Homeward Bound Program includes the following agency partners:

Dryden Native Friendship Centre, Dryden Literacy Association, Kenora District Services Board,

Confederation College, Ontario Aboriginal Housing Services, City of Dryden.

This release of information is only valid from _________ (today' s date) until

(one year from today).

I am aware that only with my complete agreement and understanding is this release valid.

Applicant signature: --------------- Date:

Witness Signature: ______________ _ Date: