APPLICATION FORM

Please fill in this form in black ink.

All information will be treated in the strictest confidence

Programme / Start Date
Name
Address
Post Code / Country of Birth
Gender / National Insurance No.
Telephone / Mobile
Date of Birth / Age
How did you hear about Catch22? Please tick the most appropriate box:
School / College / Friend / Careers
Event / AVMS / News-
Paper / Website / Leaflets
Employer / Name and Post Code
Youth Engagement Service / Please specify which centre
Please list any qualifications or expected grades below:
GCSE/A or AS Levels / NVQ/Key Skills / Grade / GCSE/A or AS Levels / NVQ/Key Skills / Grade
Previous School / Leave Date
Previous College/
Training Provider / Course Details / Leave Date
What are you currently doing?
Employed / Unemployed / School / College
Other
Career Choice / 1st / 2nd / 3rd
In case of an accident or emergency, please give details of an emergency contact:
Name / Relationship
Address
Postcode / Telephone / Mobile
Health – This information will ONLY be used to identify any support you may need.
Do you have any disability or health problem which affects your ability to carry out your normal daily activities? Yes / No
01 / Visual impairment / 08 / Temporary Disability after illness/accident
02 / Hearing impairment / 09 / Profound Complex Disabilities
03 / Disability affecting mobility / 10 / Aspergers Syndrome
04 / Other physical disability / 90 / Multiple Disabilities
05 / Other medical condition (Diabetes/Asthma/Epilepsy) / 97 / Other
06 / Emotional/Behavioural Difficulties / 99 / Not Known/none provided
07 / Mental health difficulty
Are you taking any medication that we should be aware of: Yes / No
If yes please indicate what medication:
Registered with GP Yes / No
Registered with dentist Yes / No
Allergies: please give details
Do you have any learning difficulties which affect your ability to carry out your normal daily activities?
Yes / No
01 / Moderate learning difficulty / 20 / Autism spectrum disorder
02 / Severe learning difficulty / 90 / Multiple Disabilities
10 / Dyslexia / 97 / Other
11 / Dyscalculia / 99 / Not Known/none provided
19 / Other specific learning difficulty
I declare to the best of my knowledge the information I have given is correct.
Signed / Date
FOR CATCH22 USE ONLY
Interview Date / Interviewed By
Hobbies
Travel
General comments/IAG. Other relevant information e.g. social problems, support required etc. Any information for employers, e.g. time off required for prayer or hospital appointments etc.
Please bring the completed application form with you or return it to:
Catch22, C1, Abingdon House, Cumberland Business Centre, Portsmouth, PO5 1DS
Tel: 02392 861228 Fax: 02392 374295

Personal Information (continued)

Is or has the young person ever been “looked after”? eg. Care leaver Yes / No
Please give details:
Has the young person had any involvement with the police? Yes / No
Please give details:
The following information is required for statistical information and is treated as confidential. Please tick the appropriate boxes.
Faith / Sexuality
Agnostic / Jewish / Heterosexual
(Straight) / Lesbian
Buddhist / Muslim / Transsexual
Catholic / Sikh / Bisexual / Unknown
Christian / Other / Gay Male / No Answer
Hindu / No Answer
Ethnic origin questions are not about nationality, place of birth or citizenship, but about colour and broad ethnic group. UK citizens can belong to any groups listed. To help see how our Equal Opportunities Policy is working, please tick which of the following categories best describes you.
Code / Ethnic Origin / Code / Ethnic Origin / Code / Ethnic Origin
31 / White British / 37 / White and Asian / 43 / Other Asian
32 / White Irish / 38 / Other Mixed / 44 / African
33 / Gypsy or Irish Traveller / 39 / Indian / 45 / Caribbean
34 / Any Other White Background / 40 / Pakistani / 46 / Any Other Black/Caribbean
35 / White and Black Caribbean / 41 / Bangladeshi / 47 / Arab
36 / White and Black African / 42 / Chinese / 97 / Any Other/Not Known