COASTAL LEISURE LEARNING A Community Interest Company Enrolment Form 2014-2015 PLEASE COMPLETE ONE FORM FOR EACH PERSON Extra forms are available to download from www.coastalleisurelearning.co.uk if needed COURSE REQUIRED:_____________________________________________ CODE No. AC/04/S/_________ COURSE REQUIRED:_____________________________________________ CODE No. AC/04/S/_________ COURSE REQUIRED:_____________________________________________ CODE No. AC/04/S/_________ Title: First Name: Surname: Address: Postcode: Telephone (Work): E-Mail: Cheques payable to Coastal Leisure Learning. Electronic or card payments may be made. Please contact us for details. (Home): Amount enclosed: Course AC/04/S/ £ Course AC/04/S/ £ Course AC/04/S/ £ £ Send to: Coastal Leisure Learning, 13 Leiston Enterprise Centre, Eastlands Ind. Estate, Leiston. IP16 4US If you are receiving an income based benefit, you may be entitled to claim a concession. Proof of benefit must be provided. Please contact us on 01728 833171 or email [email protected] for details Type of benefit: ____________________________________________________________________ To be completed by learner: I have received appropriate information relating to the course. I understand that false information given may lead to inappropriate use of public funds and I confirm that all information is correct to the best of my knowledge. Learner Signature: Date: To be completed by Tutor: Tutor signature: FOR COMPLETION BY OFFICE STAFF No of Amount Weeks Term 1 Term 2 Term 3 Workshops Date: Date Receipt No. Cash/ Cheque Evidence of Benefit seen COASTAL LEISURE LEARNING Community Interest Company Gender: Male Female Date of Birth: Have you been permanently resident in England for the last 3 years? / Yes / No If NO, please: a) complete a RESIDENT FORM (available on request) b) state the country you lived in before settling in England Ethnicity: Arab Black or Black British – African Mixed – any other mixed background Asian or Asian British – Bangladeshi Black or Black British – Caribbean White – British Asian or Asian British – Chinese Black or Black British – any other Black background White – Irish Asian or Asian British – Indian Mixed – White and Asian White – Gypsy or Irish Traveller Asian or Asian British – Pakistani Asian or Asian British – any other Asian background Mixed – White and Black African White – any other White Mixed – White and Black Caribbean Any other ethnic group Disability: The Disability Discrimination Act considers a person disabled if: • You have a longstanding physical or mental condition or disability that has lasted or is likely to last at least 12 months, and • This condition or disability has a substantial adverse effect on your ability to carry out normal day-to-day activities. Do you have a disability and/or a learning difficulty? Yes No If yes please tick the appropriate box: Visual impairment Hearing impairment Mobility impairment Other physical impairment Medical condition Mental health difficulty Temporary impairment after illness / accident Multiple impairment Moderate learning difficulty Severe learning difficulty Multiple learning difficulty Dyslexic Other impairment or difficulty, please specify: Learner Support: I require additional support as a learner (if ticked, your tutor will discuss what support is available and will ask for your permission for this information to be shared) Please tell us how you found out about this course: Returning Learner Library Friend/Relative Flyer / brochure School Job Centre + Health Professional Employer/Union Newspaper Website Centre Staff / Tutor Information Advice Guidance How We Use Your Personal Information The personal information you provide is passed to the Chief Executive of Skills Funding (“the Agency”) and, when needed, the Young People’s Learning Agency for England (“the YPLA”) to meet legal duties under the Apprenticeships, Skills, Children and Learning Act 2009, and for the Agency’s Learning Records Service (LRS) to create and maintain a unique learner number (ULN). The information you provide may be shared with other partner organisations for purposes relating to education or training. Further information about use of and access to your personal data, and details of partner organisations are available at: http://skillsfundingagency.bis.gov.uk/privacy.htm http://www.ypla.gov.uk/privacy.htm http://www.learningrecordsservice.org.uk/documentlibrary/documents/Code+of+Practice+for+Sharing+of+Personal+Information.htm Please select your preferred method(s) of contact: Post Telephone Tick this box if you do not wish to be contacted about courses or learning opportunities Tick this box if you do not wish to be contacted for survey and research To help our funders monitor their Equality & Diversity Policy, please complete this form as fully as possible. Thank you. E-Mail