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 project are you interested to join?

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

PERSONAL DETAILS




Date of Birth:
Gender:
Gender - self description:


Leave message?:
Address Street:
Address Postcode:
Borough:
Is this applicant's home address?:
Home Address Street:
Home Address Post Code:
Home address borough:

Emergency Contact Name:
Emergency Contact Phone Number:
Emergency Contact Email:
Name of GP:
GP phone number:
Address of GP:

MENTAL HEALTH

Mental distress hospitalisation:
Hospitalisation details:
Mental health diagnosis:
Mental health diagnosis details:
Past prescribed medication:
Past medication details:
Current medication:
Current medication details:
Description of current mental health:

OCCUPATION

Employment 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 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: