I, hereby authorize S.U.C.C.E.S.S. AEIP PRE-ARRIVAL SERVICES PROGRAM to hold and/or release my personal and service information to:

• AEIP Pre-Arrival services for the purpose of providing pre-arrival settlement services leading to post arrival services
• IRCC for the purpose of statistical collection of data and give consent for Future Research/Consultation
• AEIP Canadian Partners (S.U.C.C.E.S.S. ISIP, CCIS, SODS, COSTI, MCAF, ISANS, Success Skills Centre)

I give consent to receive email information and/or notification from the AEIP Virtual Service Centre of pre-arrival and post arrival settlement information, webinars and online activities for preparing to live in Canada. I consent to receive emails about AEIP news, events, updates and other valuable information.

I understand that as an approved client of the S.U.C.C.E.S.S. AEIP Pre-arrival services program, I will be served with equality without prejudice towards age, race, or gender identity. Information shared on this form will be kept confidential in accordance with federal and provincial privacy legislation and will be used only to assist staff in providing service, determine service eligibility, and generate anonymous statistics. Confidentiality of the information can only be breached when: required by Canada’s federal and provincial laws or by an order of court; there is reasonable ground to believe that such release will prevent harm; it is necessary to disclose the information to the personnel of S.U.C.C.E.S.S. or accreditation agencies that are authorized to receive such information in the course of their duties. S.U.C.C.E.S.S. is required to record information pertaining to personal and service information on a federal Immigration, Refugees and Citizenship Canada database that monitors service outcomes. All records are confidential and retained in a secure and protected environment. I agree to the above stated use of my personal information. If I have any further questions I can contact the Manager in charge of this service.

CLIENT RIGHTS: S.U.C.C.E.S.S. respects the rights and dignity of all individuals, families and groups we serve. We treat clients with consideration and respect their personal autonomy and privacy. The Right to Choose – S.U.C.C.E.S.S. services are voluntary and non-coercive except for those which are mandated by law or court order. S.U.C.C.E.S.S. respects clients’ rights to choose services and service providers. We provide clients with information of alternative choices. Individuals, families and/or legal guardians have the right to participate in decisions regarding the services provided. When clients choose to seek service from other sources or when clients’ needs are found to be better met by other organizations, we shall provide relevant information and referral to facilitate their choice. Right to Fair and Equitable Access – S.U.C.C.E.S.S. is committed to providing its clients fair and equitable access to service. If a service is available only to a population subgroup, the eligibility criteria will be clearly defined. Except for emergency situations, access to service is on a first come first served basis. Right to Non-discrimination – S.U.C.C.E.S.S. personnel shall not discriminate clients on the basis of race, colour, ancestry, place of origin, political belief, religion, marital status, family status, physical or mental disability, sex, sexual orientation, or age. Right to Culturally Competent Service – S.U.C.C.E.S.S. recognizes, respects, and responds to the needs of clients and provides service that is culturally and linguistically appropriate to the client. S.U.C.C.E.S.S. implements practices within the agency to ensure that programs and services reflect the culture, languages and traditions of the people served. Right to Confidentiality and Privacy Protection – S.U.C.C.E.S.S. treats all client information as confidential and will not release client information inside or outside the organization without the client’s written authorization. CLIENT RESPONSIBILITIES: S.U.C.C.E.S.S. clients have the responsibility to respect other clients and to observe program schedules. Respecting Others – Clients are expected to respect the rights, dignity and privacy of other persons they meet at S.U.C.C.E.S.S. Any behaviour or action which threatens the safety or violates the rights of another client or S.U.C.C.E.S.S. personnel may result in service termination. Observe Program Schedule and Rules – Clients are responsible for following and respecting S.U.C.C.E.S.S. programs schedules and rules. Feedback to S.U.C.C.E.S.S. – S.U.C.C.E.S.S. welcomes clients’ feedback about its service and suggestions for improvement.

I understand that the information provided by AEIP: 

• Is as accurate as possible on the date(s) it is given; and
• Should NOT be considered as legal advice
• This form will expire in one year from the date of signing

I agree to the terms stated in this document and further certify that checking this box counts as an electronic signature.