Stronger Together Leader Survey Report

Notice with Respect to Collection of Personal Information

The information on this form is collected under the authority of the Municipal Freedom of Information and Protection of Privacy Act and the Freedom of Information and Protection of Privacy Act. This information will be used for the delivery of Wellington County Learning Centre programs and services; and the maintenance of related databases, registries and related research, in compliance with legal and regulatory requirements. Any questions about the collection of this information should be addressed to Ken Harvey, Circles Coordinator at 1.800.265.7294 x 3062.

Name

Date of Birth

Gender

Male Female Nonbinary

How do you describe your racial or ethnic background?

Other Race/Ethnicity

Current Employment Status

Unemployed Part-time Full-time Self-Employed

Monthly household earned income

For the last 30 days: includes all income: gross wages, child support, pension.

First Circle Leader gross earned income

Second Circle Leader gross earned income

Other adult (age 18 and above) earned income

Child support received

CPP benefits

OW Benefits

EI

Child Tax Benefit

Ontario Childcare Supplement

Universal Childcare Benefit

O.D.S.P Benefits

O.S.A.P

Any Other Income

TOTAL Gross Monthly Income for last 30 days

Debt

Credit Cards

Medical/Dental

Student loans

Other

TOTAL Unsecured Debt

Cash Assets

Chequing account(s) balance (Total current balance)

Saving account(s) balance

Cash on hand

Investments

TOTAL Cash Assets

Housing

Own Rent Other

Support Network: In times of trouble I have the following number of friends or family I can count on for help (people outside of my household)

Safe and stable place to live? (There is no threat of eviction in the next 3 months)

Yes No

Reliable means of transportation? (I can get to & from work, school store & medical appointments)

Yes No

My Household Size is:

Number of Adults (age 18 & above)

Number of Children (under 18 years of age)

I consider myself a person who is experiencing:

Generational Poverty (Two or more generations of my family have lived in poverty) Situational Poverty (My family's poverty is due to trigger event(s) ie. illness, divorce, long-term, unemployment, etc.)

Major pathway to economic stability (check all that apply):

Employment Education Other

Completed Circles' Job Readiness Training

Yes No

Any additional information about your current situation:

148 George Street, Arthur, N0G 1A0

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