Recovery Education Centre - Registration Form

Name of course

Location of course

Start date of course

January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031

Section 3: Additional Support/Assistance

Is English your first language? *

Yes No

If you indicated that English is not your first language, do you feel that you might need assistance in understanding the course content?

Yes No

If you have any learning difficulties/disabilities (such as hearing or visual impairment) or medical conditions (such as epilepsy or diabetes), please state them in the box below. This information will only be shared with the trainers, if it is felt necessary to safeguard your wellbeing, and enhance your learning experience within the Recovery Education Centre.

Section 4: Student Declaration

Please indicate whether you have any unspent "relevant" criminal convictions. Relevant unspent criminal convictions against a person (whether violent or sexual), and offences involving drugs or controlled substances. *

Yes No

Having an unspent relevant criminal conviction does not automatically mean that you will be unable to access a course within the Recovery Education Centre, however the staff team within the Recovery Education Centre will meet to discuss your application.

Equal Opportunities Monitoring

The NHS has an absolute commitment to equality in the services we provide.

The information provided here is only used to monitor and analyse how services are provided.

Please answer all questions.

1. Age *

Up to 16 17 - 25 26 - 50 51 - 74 75 and Over I do not wish to disclose my age

2. Sex / 3. Gender Reassignment *

Select Male Female Transgender I do not wish to disclose my sex

4. Marital Status *

Select Single Married Civil Partnership Widow/Widower I do not wish to disclose this information

5. Ethnic Origin

Asian or Asian Background Black or Black British Multi-cultural White Other I do not wish to disclose my ethnicity

Asian or Asian Background

Bangladeshi Indian Pakistani Any other Asian Background

Black or Black British

African Caribbean Any other Black Background

Multi-cultural

Select White & Asian White & Black African White & Black Caribbean Any other Mixed Background

White

British English Irish Scottish Welsh Any other White Background

Other ethnic group

Chinese Gypsy Traveller Eastern European Any other Ethnic group

If you ethnic group is not listed, please state:

6. Please select the option which best describes your sexuality *

Select Heterosexual Bisexual Lesbian Gay I do not wish to disclose my sexuality

7. Please indicate your religion or belief

Select Christianity Atheism Buddhism Islam Jainism Sikhism None Judaism Hinduism Other I do not wish to disclose my religion/belief

If other, please state:

8.Disability

Do you consider yourself to have a disability? *

Yes No I do not wish to disclose this information

9. Maternity

Are you pregnant at time of completing this form? *

Yes No I do not wish to disclose this information

Register

By clicking to register you are confirming that the information you have supplied is correct.