START

Thank you for your interest in becoming a trainee within our social enterprise, we would like to invite you to complete this application as thoroughly as you can.

Which social enterprise are you interested in: Pick list bike shop, bakery, light industrial unit:

For Windows: Hold down the control (ctrl) button to select multiple options
For Mac: Hold down the command button to select multiple options

How did you hear about us?:

PERSONAL DETAILS




Date of Birth:
Gender:
Gender - self description:
Address Street:
Address City:
Address County:
Address Postcode:
Is this applicant's home address?:
Home Address Street:
Home Address City:
Home Address Post Code:



Emergency Contact Name:
Emergency Contact Phone Number:
Support E-mail:
Name of GP:
GP phone number:
Address of GP:

MENTAL HEALTH

Hospital admission for mental distress:
Diagnosed with Mental Illness?:
If yes, what was the diagnosis:
Are you on medication?:
Medication:
Describe your current mental health:

OCCUPATION

Income Status:
Previous Work and Hobbies/ Interests:

OUTCOMES FOR PLACEMENT AND SUPPORT NEEDS

Placement Expectations:

For Windows: Hold down the control (ctrl) button to select multiple options
For Mac: Hold down the command button to select multiple options

Other Outcomes:
Physical Disabilities:
Audio/Visual or Mobility Issues:
Other Support Needs:

In order for us to process your application we need you to supply the details of someone who has recently been supporting or working with you and that we can contact for further information.

Referee First Name:
Referee Last Name:
Referee Organisation and Department:
Role in Relation to Applicant:
Referee Street Address:
Referee County:
Referee City:
Referee Postcode:
Referee Phone:
Referee Mobile:
Referee E-mail:

Optional: you do not need to fill in the following questions if you do not wish to, however we appreciate if you do, as it helps us to ensure that our services reach the widest possible audiences and that they are available to sections of the public that may be underrepresented. This part of the application will be kept separately and anonymously for monitoring purposes only.

Ethnicity:
Ethnicity Sub Category:
Religion or Belief:
Other Religion or Belief:
Sexual Orientation:
Other Sexual Orientation:

CONSENT

Consent: