Enrolment questionnaire

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Eligibility for free courses check *

All three criterion need to be met to receive the course for free. Evidence will be required in form of photo I.D & income proof or up-to-date benefit entitlement letter

I confirm that as of 31.08.2023 I am 19 or older

I confirm that I live in Lincolnshire

I confirm that I have a personal income of under £20,319 OR I receive state benefits

Do you have a learning difficulty or disability *

Yes

No

Please select all that apply

Vision impairment

Hearing impairment

Disability affecting mobility

Profound / complex disabilities

Social and emotional difficulties

Mental health difficulties

Moderate learning difficulty

Severe learning difficulty

Dyslexia

Dyscalculia

Autism spectrum disorder

Asperger's syndrome

Temporary disability after illness / accident

Speech, language & communication needs

Other physical disability

Other specific learning difficulty

Other medical condition

Other learning difficulty

Other disability

Prefer not to say

Application for a free course / reduced fee *

Please confirm your situation to confirm your eligibility to concessions. You will need to provide proof of this in the upload box below these options.

I am in receipt of Employment and Support Allowance (all categories)

I receive Job Seekers Allowance

I receive Universal Credit

I am in receipt of other State Benefits

I earn less than £20,319 per year

I am unemployed and in receipt of state benefit and wish to enter employment

I do not have a full level 2 (5 GCSEs at grade C or above or 4-9/up to 3 AS levels)

I was aged over 65 on or before 31.08.2023

I am an offender serving my time in the community

I am an asylum seeker in receipt of the equivalent of income-based benefit (assistance under the terms of the Immigration and Asylum 1999)

Household situation *

No household member is in employment and the household includes one or more dependent children

No household member is in employment and the household does not include any dependent childrent

Learner lives in a single adult household, irrespective of their employment status, with one or more dependent children

None of the above applies

Learner support

Do you require any financial assistance to complete this course - for example childcare or transport assistance

Yes

No

Learner Support *

Do you require any personal support to complete this course - for example Literacy or Numeracy support

Yes

No

I confirm that I am aware I will need to pay student membership and text book costs for qualification courses *

These costs can be reimbursed by your work/employability coach - but please check with them before committing .

I confirm