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 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.
