The Financial Empowerment and Economic Well-Being Initiative (FEEWI) and Emerging Leaders Fellowship (ELF)

Central Intake: FEEWI and Emerging Leaders Fellowship

This intake form helps Ase Community Foundation understand which of our programs is best suited to you. The programs include the Emerging Leaders Fellowship (ELF) and the Financial Empowerment and/or Economic Well-Being Initiative (FEEWI).

FEEWI supports Black Canadians with disabilities and their families through free access to disability benefits navigation, tax filing support, financial coaching and education.

The Emerging Leaders Fellowship is a free 8-week career program for Black disabled and neurodivergent Youth, Women and Gender-diverse persons. Each cohort will receive 4 weeks of virtual self-development sessions and 4 weeks of hands-on experience, with supports to help you succeed.

All information is kept strictly confidential and will be used solely to develop our services and programs and identify ways to better serve you.

Fields marked with * are required.

Note for Participants Under 18
If the participant is under 18 years of age, a parent or legal guardian must provide consent.

Your privacy is our priority. All information provided in this survey will remain confidential and will be used solely to improve our services and programs to better serve you.

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1. Participant's full name (Required.)

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2. If someone other than participant, please list:

Your full name

Relationship to Participant

Your email

Your phone

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3. If participant is under 18, please confirm parent or legal guardian consent

I consent

I do not consent

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4. Participant's Email Address (Required.)

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5. Participant's Phone Number (Required.)

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6. Participant's age (Required.)

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7. Participant's Gender Identity (Required.)

Female

Male

Gender Diverse

Prefer to self-describe (see Q10)

Prefer not to say

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8. If you selected 'Prefer to self-describe', please describe your gender identity

All information provided below should be the participant's information

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9. Do you self-identify as Black? ( African Canadian, Black, Afro-Caribbean, Afro-Latino, Afro-Indigenous, African American, or mixed-race of African descent) (Required.)

Yes

Prefer not to answer

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10. Do you identify as a person with a disability or multiple disabilities?

In Canada, a disability is defined under the Accessible Canada Act as any physical, mental, intellectual, cognitive, learning, communication, or sensory impairment—or functional limitation—that, in interaction with a barrier, hinders a person's complete and equal participation in society. It includes permanent, temporary, or episodic conditions, whether evident or not.) (Required.)

Yes

Unsure

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11. Do you identify as neurodiverse/neurodivergent? (Diagnosed, Undiagnosed, or Self Diagnosed)

Neurodivergence is an umbrella term that refers to the natural variation in how people think, learn, process information, and experience the world. It includes differences such as ADHD, autism, learning disabilities, and mental health conditions. These are not deficits, but differences that reflect the diversity of human brains.

Yes

Not sure

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12. What would you most like support with? Please select all that apply. (Required.)

Understanding my disability

Gaining volunteer experience or finding a job (including resume/job application/LinkedIn / interview support)

Exploring career options and skills development

Workplace accommodations plan and workplace rights

Applying for disability benefits

Filing my taxes

Budgeting, money management, credit or debt management

Financial coaching/planning

Mental health support and personal coaching

I'm not sure what support I need

Other (please specify)

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13. Do you require any accommodations or accessibility supports to communicate with us or participate in our programs? Select all that apply.

I do not require support

Extra processing time

Sensory accommodations

Accessible documents

ASL/interpreting / TTY

Captioning

Mobility/physical access

Technology/internet access

Transportation

Flexible timing

Support person

I am unsure

I would prefer to discuss this privately with staff

Other (please specify)

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14. I consent to Ase Community Foundation collecting and using the information provided in this form to determine my eligibility, connect me to appropriate programs/services, provide support and meet program evaluation/reporting requirements in accordance with Ase's privacy practices. (Required.)

I agree

I do not agree

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15. How did you hear about Ase Community Foundation/this program? (Required.)

Partner organization

Social media

Ase newsletter

Ase event

Friend/family member

School

Employment service

Healthcare provider

Community organization

Other (please specify)

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16. Which province or territory are you currently living in? (Required.)

Alberta

British Columbia

Manitoba

New Brunswick

Newfoundland and Labrador

Northwest Territories

Nova Scotia

Nunavut

Ontario

Prince Edward Island

Quebec

Saskatchewan

Yukon

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17. Do you live in the Greater Toronto Area of Ontario, Canada?

Please note that for the Emerging Leaders program, you must reside in the Greater Toronto Area in order to be eligible to attend the program.

Toronto

Peel Region

York Region

Durham Region

Halton Region

No, I do NOT live the Greater Toronto Area

Other (please specify)

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18. To help confirm eligibility for benefits and tax-related supports, please confirm your are a Canadian Citizen, Permanent resident, Refugee claimant or protected person, Temporary resident of 18 months or more (eg. work or study permit) (Required.)

Canadian Citizen

Permanent resident

Refugee claimant or protected person

Temporary resident of 18 months or more (e.g., work or study permit)

Prefer not to answer

Other (please specify)

The Financial Empowerment and Economic Well-Being Initiative (FEEWI) and Emerging Leaders Fellowship (ELF)

Central Intake: FEEWI and Emerging Leaders Fellowship

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* 1. Participant's full name (Required.)

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* 2. If someone other than participant, please list:

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* 3. If participant is under 18, please confirm parent or legal guardian consent

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* 4. Participant's Email Address (Required.)

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* 5. Participant's Phone Number (Required.)

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* 6. Participant's age (Required.)

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* 7. Participant's Gender Identity (Required.)

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* 8. If you selected 'Prefer to self-describe', please describe your gender identity

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* 9. Do you self-identify as Black? ( African Canadian, Black, Afro-Caribbean, Afro-Latino, Afro-Indigenous, African American, or mixed-race of African descent) (Required.)

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* 12. What would you most like support with? Please select all that apply. (Required.)

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* 13. Do you require any accommodations or accessibility supports to communicate with us or participate in our programs? Select all that apply.

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* 14. I consent to Ase Community Foundation collecting and using the information provided in this form to determine my eligibility, connect me to appropriate programs/services, provide support and meet program evaluation/reporting requirements in accordance with Ase's privacy practices. (Required.)

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* 15. How did you hear about Ase Community Foundation/this program? (Required.)

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* 16. Which province or territory are you currently living in? (Required.)

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* 17. Do you live in the Greater Toronto Area of Ontario, Canada?Please note that for the Emerging Leaders program, you must reside in the Greater Toronto Area in order to be eligible to attend the program.

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* 18. To help confirm eligibility for benefits and tax-related supports, please confirm your are a Canadian Citizen, Permanent resident, Refugee claimant or protected person, Temporary resident of 18 months or more (eg. work or study permit) (Required.)

1. Participant's full name (Required.)

2. If someone other than participant, please list:

3. If participant is under 18, please confirm parent or legal guardian consent

4. Participant's Email Address (Required.)

5. Participant's Phone Number (Required.)

6. Participant's age (Required.)

7. Participant's Gender Identity (Required.)

8. If you selected 'Prefer to self-describe', please describe your gender identity

9. Do you self-identify as Black? ( African Canadian, Black, Afro-Caribbean, Afro-Latino, Afro-Indigenous, African American, or mixed-race of African descent) (Required.)

12. What would you most like support with? Please select all that apply. (Required.)

13. Do you require any accommodations or accessibility supports to communicate with us or participate in our programs? Select all that apply.

14. I consent to Ase Community Foundation collecting and using the information provided in this form to determine my eligibility, connect me to appropriate programs/services, provide support and meet program evaluation/reporting requirements in accordance with Ase's privacy practices. (Required.)

15. How did you hear about Ase Community Foundation/this program? (Required.)

16. Which province or territory are you currently living in? (Required.)

17. Do you live in the Greater Toronto Area of Ontario, Canada?

Please note that for the Emerging Leaders program, you must reside in the Greater Toronto Area in order to be eligible to attend the program.

18. To help confirm eligibility for benefits and tax-related supports, please confirm your are a Canadian Citizen, Permanent resident, Refugee claimant or protected person, Temporary resident of 18 months or more (eg. work or study permit) (Required.)