Registration - Kilcooley Womens Centre

Registration Form

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- Step 1 of 4

Your Name (including your title) *

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of Birth *

Contact number *

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National Insurance No *

Gender *

Age *

Kilcooley Resident *

NIHE Resident *

What is your Nationality? *

Which one of the following groups do you consider yourself to belong to? *

Do you have a Disability or Medical Condition? *

If you answered YES please state which Disability/Medical Condition *

Dyslexia
Mobility
Hearing Difficulty
Epilepsy
Learning Difficulty
Mental Health Difficulty
Physical Difficulty
Asthma
Vision Impairment
Speech Difficulty
Diabetes
Heart/Stroke
Other

Disability and Health Conditions: Refers to participants who have a current disability covered by the 1995 Disability Discrimination Act, defined as a disabled person as someone who has a physical or mental impairment that has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities.

What course are you interested in? *

Do you require additional learning support for Exams? *

If yes, evidence must be supplied by your medical professional. This must be provided at the beginning of the course in order for us to support you for the duration. Evidence will be presented to the awarding body for approval. You must inform the tutor of your condition. Decision on adjustments for exams are approved by the awarding body and not Kilcooley Women’s Centre.

Do you belong to any of the following groups? *

1 Lone Parents: Any lone parent with dependant children (children aged under 16 and those aged 16-18 who have never married and are in full-time education). 2 Migrants: A migrant is someone from outside the UK and Ireland who is resident here for a period of at least 12 months (one year). 3 Other disadvantaged: This can include, for example drug and alcohol misusers or exprisoners.

Next of Kin Details (including contact number and relationship) *

What is your marital status? *

Do you have any Dependants? *

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Please state the number of children you have under 18 *

Are you caring for an elderly person? *

Are you caring for a person with a disability? *

Do you require childcare for classes? *

ChildcarePlease list the names of the child/children, their age and the class/class childcare is required for *

Note: All relevant forms much be filled in with a member of Ladybirds staff in order to secure your childcare place.

What is your Community Background? *

Are you receiving any Benefits? *

If yes please state

Labour market status, before entering

Please choose *

Employed
Unemployed
Still at School
School leaver
Long-term Sick
**Economically Inactive but not in Education or Training

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Employed (State Hours) *

Type of Employment (please state) *

*Unemployed: Not working, but were looking for work before entering the Project. ** Economically Inactive but not in Education or Training: Those in Retirement, Self-Employed, Sick, Disabled, Fulfilling domestic task, Looking after home/family.

How long have you been Unemployed? *

Less than 6 months
Between 6-12 months
12 Months or more

Do you consider yourself to be not in employment, education or training? *

If your in education or training, please specify: *

Are you a New Entrant /Returner to the Labour Market? *

New Entrant: Those who have never worked in a full-time, permanent position, and have never looked for such a position e.g. School Leavers. Returner: Those who have worked in the past but who were absent from the labour market, not working, and not looking for work, for a period of any time, for any reason e.g. Sickness/Training.

Educational Attainment *

Please give details of your highest qualifications achieved. Please note qualifications such as NVQs, BTecs, OCR Nationals, Functional Skills and diplomas can be awarded at different levels.

How did you find out about Kilcooley Women’s Centre? *

Have you been referred to this Programme? *

If Yes, please give details of referral *

Have you been on another Government Programme? *

If Yes, please give details *

About You

What is your country of birth? *

If born outside the UK, how long have you been, or expect to be, resident in the UK? *

Are you legal resident in a European Member State? *

Are you able to take up employment in the UK? *

Do you consider that you belong to an ethnic minority group? *

Are you part of a family that will receive Community Family Support on the programme? *

Household Situation

Please choose the option which best describes your current household situation *

Living in a Jobless Household
Living in a Single Adult Household with dependent children
Living in a Jobless Household with dependent children
Homeless or affected by Housing Exclusion
None of the above

I would like to receive communications from Kilcooley Women’s Centre in relation to future activities or courses. *

Do we have your permission to use any photographs we may take of yourself for publication purposes? *

Yes
No (If No it is your responsibility to avoid cameras whilst taking part in activities)

Are you under 18? *

Under 18: Parent/Guardian Consent
I agree to:

The young person taking part in the stated activity. This could include face to face inside a classroom, blended or virtual activities using web conferencing platforms or outdoor activities such as gardening. *

The young person taking part in the stated activity. This could include face to face inside a classroom, blended or virtual activities using web conferencing platforms or outdoor activities such as gardening.

Kilcooley Women’s Centre keeping a record of this form for funding requirements. *

Kilcooley Women’s Centre keeping a record of this form for funding requirements.

Any medical treatment that the young person may need to be given in an emergency. *

Any medical treatment that the young person may need to be given in an emergency.

The young person being filmed or photographed during the activity, with the possibility that these photographs/media recordings may be used for publications or marketing publicity (Kilcooley Women’s Centre will take all steps to ensure these images are used solely for the purposes for which they are intended). *

The young person being filmed or photographed during the activity, with the possibility that these photographs/media recordings may be used for publications or marketing publicity (Kilcooley Women’s Centre will take all steps to ensure these images are used solely for the purposes for which they are intended).

Name, Relationship & Date *

DATA PROTECTION DECLARATION UNDER GDRP: I confirm I give my consent to the processing of my personal data for 1 or more specific proposes. I understand information will be used in accordance with requirements of funding organisations; and the legitimate interests pursued by the controller or 3rd party except if overridden by interests and fundamental rights and freedoms of the data subject which requires protection of personal data, especially of a child. This will not be applied to processing by public authorities and government departments in the performance of their tasks. PARTICIPANT DECLARATION: I declare that the details given on this form are true to the best of my knowledge and maybe kept for as long as required. Any personal information about you or your family that is contained within our filing system (computer or manual) will only be used for the purposes for which it was collected. I agree to abide by the rules of Kilcooley Women’s Centre as outlined in the group rules.

Participant Signature *

Today's Date *

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