Career Launchpad Personal Career Plan

Name* This field is required.

First Name

Last Name

Preferred Name / Other Name(s) Used:

Social Security Number: [or other CA Gov identifier]:

Date of Birth

Date

Phone Number* This field is required.

Please enter a valid phone number.

Email* This field is required.

example@example.com

Gender

Male

Female

Other

Decline to state

Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Mailing Address (if different):

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

What is your race and ethnicity?

White (non-Hispanic): This includes people of European descent, such as German, Irish, Italian, English, and others.

Hispanic or Latino: This category includes people of Mexican, Puerto Rican, Cuban, and other Latin American descent.

Asian: California has a significant Asian population, including Chinese, Filipino, Indian, Vietnamese, Korean, Japanese, and others.

African American: This refers to people of African descent who have roots in various African countries.

Native American: California is home to several Native American tribes, including the Chumash, Pomo, Hupa, Yurok, and many others.

Pacific Islander: This includes people of Hawaiian, Samoan, Guamanian, and other Pacific Islander descent.

Middle Eastern: This category encompasses people from countries in the Middle East, such as Iran, Iraq, Syria, Lebanon, and others.

Multiracial: California also has a significant population of individuals who identify with multiple racial backgrounds.

Other

Decline to state

Do you currently have a

Individualized Education Program

504 plan

Name of school or last attended institution:

Grade Level Attained:

Parent/Guardian Name

First Name

Last Name

Parent/Guardian Phone Number

Please enter a valid phone number.

Parental /Guardian Consent (if applicable)

How were you referred to the Career Launchpad program?

Online search

Social media

Word of mouth

School or educational institution

Community organization or center

Flyer or poster

Email newsletter

Event or conference

Website or blog

Referral from a friend or family member

Other

Please describe your disability/disabilities

How does your impairment/disability/disabilities impact you in your daily activities, school, and job search activities?

Which Career Launchpad program streams will you participate in?

Job Exploration Counselling

Student Placement and Paid Work Experience Services

Workplace Readiness Training

Please input any detail regarding the School from which the participant enrols and/or school career counsellor contact, if applicable.

Please input any additional personal information regarding health and medical data pertaining to the clients impairment or disability here.

Career Launchpad Personal Career Plan