Prospect Human Services

Please provide us with the following information to help us determine the service that is best for you.

First Name

Last Name

Where do you live? City

Province

Phone

Preferred Language

Please give us an idea of the type of employment-related services you are looking for:

Do you have a disability?

Yes

Prefer Not to Report

If yes, please let us know what kind of disability so we can plan for appropriate supports:

The personal information you provide is being collected to determine eligibility for funded employment and training programs offered by Prospect. If you choose to apply, your personal information will be used and disclosed in the application process for ongoing eligibility verification, delivery of programs, benefits or services, and to evaluate the effectiveness of programs and services offered by Prospect.

The personal information provided is collected, used and disclosed under the authority of sections 33-40 of the Freedom of Information and Protection of Privacy Act and various statutes establishing the programs. A list of programs, including the legislation authorizing each program, is available online. Go to http://www.humanservices.alberta.ca/authorizing-legislation.html .

If you have questions about the collection, use or disclosure of your personal information, please contact an Alberta Supports Coordinator if you are in an Alberta Supports Centre or contact the Alberta Supports Contact Centre at 1-877-644-9992 or 1-780-644-9992 (Edmonton).

I have read, and agree to, the above statement

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