Student Assistance Program Application

Personal Information

Full Name

First Middle Last

Status Card Number

CAFN Beneficiary?

Yes

Date of Birth

Social Insurance Number

Phone 1

Phone 2

Male/Female

Male

Female

Disabled/Not disabled

Disabled

Not disabled

Are you on Employment Insurance?

Yes

Have you collected EI in the Past 3 years?

Yes

Current Source of Income

Employed Fulltime

Employed Part-time

Self Employed

Income (Social) Assistance

No Income

Other (WCB, Pension Income), etc

Please specify Other income source

Status

Status on Settlement Land

Status off Settlement Land

Non Status

Inuit

Metis

Have you applied to the Yukon Grant?

Yes

Have you applied to Provincial Funding?

Yes

Course Information

What course/program will you be taking?

What institute will you be attending?

Will the institute provide you with a T2202A FORM FOR Taxation purposes?

Yes

(You will/may be expected to pay for your education through your taxes)

When does the Program start:

When does the Program end:

Accreditation sought:

Trades Level

Part Time/Full Time

Part Time

Full Time – As defined by Institution (3 or more courses considered full time)

Expected graduation year:

# of years assistance is requested:

Mailing Address

This is your address is while you are in school

Street Address Address Line 2 City Province Postal Code

This is your permanent address when you are not going to school

Street Address Address Line 2 City Province Postal Code

Family

Marital Status

Single, living w/parents

Single-Unemployed

Single-Employed

Married w/ employed spouse

Married w/ dependent spouse

Number of Dependents

Dependant 1

Name

First Last

Age

Relationship to you

Dependant 2

Name

First Last

Age

Relationship to you

Dependant 3

Name

First Last

Age

Relationship to you

Dependant 4

Name

First Last

Age

Relationship to you

Educational History

How many Educational Programs did you completed?

Educational Program 1

Date attended from

Date attended to

Name of institution

Program

Year Completed

Educational Program 2

Date attended from

Date attended to

Name of institution

Program

Year Completed

Educational Program 3

Date attended from

Date attended to

Name of institution

Program

Year Completed

Did you graduate from High School?

Yes

What Year?

Employment History

How many jobs did you have

Job 1 Information

Name & Address of Employer

Start Date

End Date

Job Title

Name of Supervisor

First Last

Supervisor Phone

Job 2 Information

Name & Address of Employer

Start Date

End Date

Job Title

Name of Supervisor

First Last

Supervisor Phone

Job 3 Information

Name & Address of Employer

Start Date

End Date

Job Title

Name of Supervisor

First Last

Supervisor Phone

Have you applied for other sources of funding?

Yes

From where?

Have you applied to YTG Yukon Grant?

Yes

TRAINEE DECLARATION

I certify that the information above is true, correct and complete in every respect and I understand I may be subject to verification by CAFN or its representatives, I will report to CAFN as soon as possible, if there are changes in the information, I am aware legal action can be taken against me for making false statements or failing to inform CAFN of changes to the information affecting my entitlement to allowances and/or Employment Insurance benefits. I am aware that I may be disqualified from receiving benefits should I voluntary or involuntarily exit the course, or not attend on a regular basis. I hereby declare that I acknowledge the terms and conditions set out in this contract and agree that in the event that I choose not to adhere to one or more of the following, I may be exempted from future funding.

1. I am responsible to reimburse CAFN for training costs or allowances, on a per diem basis, should I voluntarily or involuntarily exit the course, or not attend on a regular basis.
2. I will provide receipts to CAFN for pre-approved training related purchases.
3. I a responsible for any costs incurred in excess of the agreed upon amount.
4. I am responsible to provide CAFN with a written evaluation of the training upon completion.

I will save CAFN harmless from and against all claims, losses, damages, costs and expenses related to any injury or death of a person, or loss or damages to property caused or alleged to be caused by this training initiative and that all necessary liability and life insurance shall be maintained by me for the duration of this activity.

TRAINEE WAIVER:

I agree and authorise that information related to this training may be shared amongst participating Provincial Ministries, Federal Departments and Public /Private Training Institutions identified as being a stakeholder.
When the option to appeal is being exercised, the written appeal is to be forwarded to the CAFN Manager of Education, Employment & Training (Attention: APPEALS) Please ask for an APPEALS FORM.

Signature of Client

Date

Note: Applications must be completed in full. Failure to do so will delay application approval.

FOR OFFICE USE ONLY

Reviewed by:

Date

Approved:

Date

Popular topics:

Popular topics:

Student Assistance Program Application

Personal Information

Course Information

Mailing Address

Family

Educational History

Employment History

TRAINEE DECLARATION

TRAINEE WAIVER:

FOR OFFICE USE ONLY