REQUEST FOR A TRIAL: Supported Employment Services (Unit 5

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REQUEST FOR A TRIAL: Supported Employment Services
(Unit 5 – 1031 Autumnwood Drive)
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For Office Use Only
Date Received: ____________________________
By: Phone_____
Mail ______
Fax ______
Received by: _______________________________
--------------------------------------------------------------------------------------------------------------Name of Participant: __________________________________________
Address: _____________________________________________________
Phone: _______________________
Email: _______________________
Name of School (if applicable): _________________________________________
Address_____________________________________________________
Phone: ________________________ Fax: ______________________
Referred by: ___________________________________________________
Position or Relationship to Participant: _________________________
Phone Number: ___________________ Email: ________________________
Best Method of Contact: Phone ___ Email ___
Proposed Trial Period (dd/mm/yyyy): ________________to _________________
Graduating Year (if applicable): ___________
EA or persons accompanying individual (if applicable):
Name: _______________________ Relationship: _________________________
Name: _______________________ Relationship: _________________________
Comments and/or Recommendations:
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Unit 8-1031 Autumnwood Drive • Winnipeg, MB., R2J 1C6
Phone (204) 257-0813
Fax (204) 257-7274
www.tlcwpg.ca