Application Form | Level It Up

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Application Form

Name*
First Last
Address*
Street Address City
Email*
Phone*
Emergency Contact*
Name Relationship Phone Number
Are you a Canadian citizen, and do you have a legal right to work?*
- Yes
- No
Are you eligible for Community Living Disability Services?*
- Yes
- No
This is a provincial government program that supports adults with intellectual disabilities in Manitoba.
Have you been fully vaccinated against Covid-19?*
- Yes
- No
If we are able to meet face to face, it is important for us to know whether you have been fully vaccinated (two shots) or not.
How did you find out about Level IT Up?*
When were you diagnosed with ASD?*
What is your understanding about your diagnosis?*
Can you use the telephone to independently make and receive calls?*
- Yes
- No
Can you use email, spell check, Microsoft word and excel, etc.?*
- Yes
- No
Do you have access to the internet?*
- Yes
- No
If yes, are there any supervision concerns we should be aware of when you access the internet?
Do you have any serious mental health concerns that could interfere with your success with Level IT Up or employment?*
- Yes
- No
If yes, please describe:
Do you take any medications for the above mental health problems?
- Yes
- No
Are you connected to a mental health support service or practitioner?*
- Yes
- No
If yes, who/where?
Have you been convicted of a felony?
- Yes
- No
If yes, please explain:
Tell us about your education:
Did you attend High School?*
- Yes
- No
If yes, where did you attend High School?
Name/Location: Number or Years Attended: Degree/Area of Study:
Did you graduate?
- Yes
- No
Did you attend College or University?*
- Yes
- No
If yes, where did you attend College/University?
Name/Location: Number or Years Attended: Degree/Area of Study:
Did you graduate?
- Yes
- No
Did you attend Graduate School?*
- Yes
- No
If yes, where did you attend Graduate School?
Name/Location: Number or Years Attended: Degree/Area of Study:
Did you graduate?
- Yes
- No
Did you attend any other form of school?*
- Yes
- No
If yes, where did you attend?
Name/Location: Number or Years Attended: Degree/Area of Study:
Did you graduate?
- Yes
- No
Tell us about your employment history:
Do you have previous work experience?*
- Yes
- No
Employer:
Employed From/To:
Start date: End date:
Position:
Duties:
Reason for Leaving:
Employer:
Employed From/To:
Start date: End date:
Position:
Duties:
Reason for Leaving:
Employer:
Employed From/To:
Start date: End date:
Position:
Duties:
Reason for Leaving:
What are your hobbies/special interests?*
What experience do you have working on or with computers?*
What experience do you have with cell phones?*
Why do you want to work with Level IT Up?*
What, if anything, do you know about the jobs of software developer, software tester, data manager or digitization?*
Do you have access to transportation to get to and from Level IT Up training/assessment services?*
- Yes
- No
Please explain:*
Do you have any behaviour that could interfere with social situations?*
- Yes
- No
If yes, please describe:
Are you able to independently attend to your hygiene and toilet needs?*
- Yes
- No
Can you write/type?*
- Yes
- No
If yes, please select your writing level:*
(check one box)
- Single words
- Sentances
- Paragraph-length
Do you use these writing skills on a daily basis?*
- Yes
- No
Are you able to work independently on activities, including homework, with minimal supervision and stay on task for a set period of time?*
- Yes
- No
Can you tolerate a group learning environment?*
- Yes
- No
Are you able to sit through 3 hour training sessions?*
(this includes breaks)
- Yes
- No
Can you focus on a task that may not be of interest, and complete simple tasks without prompting?*
- Yes
- No
Please explain:*
References:
Name:*
First Last
Relationship*
Phone*
Years Known*
Name:*
First Last
Relationship*
Phone*
Years Known*
Name:*
First Last
Relationship*
Phone*
Years Known*
What else can you tell us about yourself to help us to get to know you better?*
What types of supports/assistance do you think you may require to work with us?*
Please use past experience from school or work. Be as honest and as open as possible about what types of supports you require.

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