ESDC EMP5616 (2020-04-005) E
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Emploi et
Développement social Canada
Employment and
Social Development Canada
The information collected in this form will be used to determine your eligibility for CSJ and for subsequent analysis, research or evaluation purposes.
Completion of this form is mandatory.
ESDC, on behalf of the Government of Canada, is responsible for the evaluation of the Youth Employment and Skills Strategy (YESS) programs in order to
ascertain how beneficial these are to YESS participants. In order to conduct the evaluation activities, your Social Insurance Number will be used to link your
employment and income information from ESDC and other sources (i.e. Canada Revenue Agency for income level). Accurate information is essential for
ESDC to evaluate the program and conduct participant surveys to ensure that the YESS programs meet your needs. ESDC will also use this information for
ESDC YESS program file management and reporting of ESDC's YESS program results.
The collection and use of your information by ESDC is allowed by the Employment and Social Development Act. The information collected and its retention
period are described in the Personal Information Bank ESDC PPU 706.
The information is handled according to the Privacy Act which gives you the right to access and correct your personal information. Instructions for obtaining
your information are available at the following website address:
I have read the health and safety brochure entitled “Are you in danger?” and agreed to take on the responsibilities of maintaining a safe work
environment for my co-workers and myself.
Yes No
Date of Birth (yyyy-mm-dd)
Surname (as appears on SIN card) Given Name and Initials (as appears on SIN card) Social Insurance Number
Email Address
Permanent Address City
Province Postal Code Telephone Number
Name of Educational Institution Last Attended
Field of Study
Is this my first work experience?
Yes No
In my opinion, is this job related to my field of study?
Yes No
I was registered as a full-time student in the previous academic year.
Yes No
I intend to return to school full-time in the upcoming academic year.
Yes No
If you are not currently a student, how long have you been out of the education system?
Less than 6 months 6 months to 1 year Over 1 year Over 5 years
Highest Level of Education Completed
Elementary Secondary Completed
Secondary Incomplete
Post-secondary Completed
Post-secondary Incomplete University Incomplete (1 or more years)
University Degree
Residency Status
Canadian Citizen Permanent Resident
Refugee under the Immigration and Refugee Protection Act *see definition on page 2
Male Female
Decline to answer
Member of a Visible Minority
Yes No Decline to answer
Person with Disability
Yes No Decline to answer
What is the language that you first spoke and still speak?
English French
Indigenous Group
Registered on-reserve Registered off-reserve Non status Metis Inuit N/A
Decline to answer
Recent Immigrant *see definition on page 2
Yes No Decline to answer
ESDC EMP5616 (2020-04-005) E
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(Name of Employee)
the undersigned, give my consent to
(Name of Employer)
to release the information contained in this form regarding my participation in CSJ to ESDC. I acknowledge that the information is collected and
administered in accordance with the Privacy Act and applicable privacy laws, and that it may be used to determine my eligibility for the YESS program
and provided to ESDC for the evaluation and accountability of the YESS program.
Employee's Signature
Date (yyyy-mm-dd)
Canada Summer Jobs Basic Eligibility Criteria
Employee must:
- Be between 15 and 30 years of age at the start of the employment.
- Be a Canadian citizen, permanent resident, or person who has been granted refugee status in Canada under the Immigration and Refugee
Protection Act.
- Be legally entitled to work in Canada in accordance with relevant provincial or territorial legislation and regulations. International participants
are not eligible. Recent immigrants are eligible if they are Canadian citizens or permanent residents.
Recent Immigrant: is a person who has moved from their country of origin (their homeland) to another country to become a citizen of that country and has
been in that country for less than 5 years.
Refugee: is a person who has been forced to leave their country in order to escape war, persecution, or natural disaster.
Employee Information
The employer may complete this section on behalf of the employee, provided the employee reviews the information and signs the paper copy of the form, as
proof of consent to share the information with ESDC. A copy of the signed consent must be maintained in the employer's files and may be verified when the
project is monitored.
It is mandatory to provide the employee’s contact and personal information as identified at the beginning of this section. The name of the employee entered
should match the name used on their SIN card as this will be used to verify eligibility.
Responding to the questions on Gender, Member of a Visible Minority, Person with Disability, Indigenous Group, and Recent Immigrant is
mandatory, and is requested for program evaluation purposes.
As mentioned above, the Employee Consent to Release Information section must be signed and dated by the employee as this is the consent to release to
ESDC officials the information contained in the form.