Adult Social Care Passport

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Adult Social Care Passport - Application

First Name *

Surname *

Title (Mr/Mrs/Ms..) *

National Insurance Number *

Gender *

Male

Female

Non-binary

Other:

Address *

Postcode *

Date of birth *

YYYY

Email address *

Home phone or mobile *

Do you have any health problems or disabilities? *

Yes

Prefer not to say

Please provide further details of health problems or disabilities below, if applicable:

Ethnicity *

Arab

Asian / Asian British - Pakistani

Asian / Asian British - Bangladeshi

Asian / Asian British - Indian

Asian / Asian British - Chinese

Asian / Asian British - Other

Black / Black British - African

Black / Black British - Caribbean

Black / Black British - Other

Arab & White - Mixed

Asian & White - Mixed

Black Caribbean & White - Mixed

Black African & White - Mixed

Any other Mixed or Multiple ethnic background

Any other ethnic group

White - British / English / Scottish / Northern Irish / Welsh

White - Irish

White - Gypsy / Traveller

White - Other

Prefer not to say

Emergency contact / Next of Kin *

Please record details of all previously gained qualifications, training or learning you have undertaken below including GCSEs, apprenticeships, NVQs, short courses, training, etc, and include qualifications gained outside the UK. Please attach an additional sheet if required. *

Do you hold literacy and numeracy basic skill qualifications or ESOL upon joining? *

Literacy

Numeracy

ESOL

Prefer not to say

Required

Do you hold a Level 3 or above qualification?
*

Yes

If yes, please specify.
*

Have you graduated from University within the last 5 years? *

Yes

If yes, please specify your degree and university you attended. *

Describe your university experience, if applicable.
*

Your situation before starting this programme *

Employed

Self-employed

Unemployed

Your Employer Details (if applicable) - Name of employer, employer address, job title, start date of employment, typical working hours per week. *

If applicable please state your job title
*

If unemployed please indicate how long: *

0 to 6 months

6 to 12 months

12 to 24 months

24 to 36 months

More than 3 years

Are you a claimant or non-claimant? *

Claimant - Under 6 months

Claimant - Over 6 months

Non-claimant

Current or most recent employer *

Current or most recent employer sector *

Have you been made redundant since January 2020? *

Yes

Are you the only adult in the household and have a minimum of one dependent child aged 0-17 years? *

Yes

Prefer not to say

Do you fulfil the Right to Work criteria? *

Yes

Can you provide evidence of your Right to Work? *

ID Card & Work Permit

Passport

Birth Certificate & ID

I cannot

Please provide the name of the training course you are interested in *

What is your learning preference? *

Face to Face

Online learning

Declaration: I confirm that I am not currently taking part in any other employment learning or enterprise programme, which is funded by the Government or European Social Fund. I confirm that the information I have provided within this document is correct and accurate to the best of my knowledge and I understand the consequences of declaring false information. Please print your name and date *

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