ZOOM: Futures in Creative Media 2017

ZOOM: Futures in Creative Media 2017

APPLICATION FORM

1. Contact details & information

Title / Mr / Mrs / Miss / Ms / Other
Forename(s)
Surname
NI Number
Date of birth / D / D / M / M / Y / Y
Age group / 18-25 / 26 -30 / 31-34 / 35-39 / 40-44 / 45-49 / 50-54 / 55-59 / 60-64 / 65+
Gender / Female / Male / Transgender
Address
Postcode
Tel (home)
Tel (mobile)
E-mail

2. Employment status

Working Full Time / Working Part Time / Full Time Student
Unemployed and claiming an out-of-work benefit / Unemployed and not claiming an out-of-work benefit

3. Which benefits are you currently claiming?

Carer’s Allowance / Child Benefit / Child Tax Credit
Employment Support Allowance / Housing Benefit / Income Support
Job Seekers Allowance / Universal Credit / Working Tax Credit
Personal Independence Payment / Disability Living Allowance Discretionary Housing Payment
OTHER

4. Education and Training (please provide details of education and qualifications, including any training courses)

GCSE/BTEC

A Level

NVQ

Other

BA/MA/Other

5. Work experience (provide details of your previous work experience, paid or unpaid)

6. Any relevant experience (include any previous involvement in film, TV or the arts)

7. Why are you applying for this scheme?

8. What barriers do you face to gaining employment/other opportunities and progressing in film/TV?

(Please tick all that apply, and rate on score of 1-3)

Area / Tick all that apply / Score (1 lowest, 3 highest)
Confidence barriers
Lack of motivation
Race discrimination experience
Sex discrimination experience
Physical or mental health experience
Non graduate/low education level
Practical skills/knowledge in film/TV
Job seeking skills
CV writing/interview skills
Isolation – lack of networks and contacts
Knowing how to progress in film/TV career
Work placement/volunteer experience
Childcare needs
Other (please specify)

9. Family

Are you:

A single adult with no children / A single parent with children
An adult with a partner, but no children / An adult with a partner and children

How many children do you have under the age of 18?None / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8

How many children of these children are aged under 5?None / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8

10. Housing

Are you:

A home owner / Living in a private rented property
Living in a permanent social housing rented property / Living in a temporary accommodation
Other (please provide details):
If you are live in social housing, who is your landlord?
(e.g. Tower Hamlets Homes, Poplar HARCA, etc.)

Are you affected by the housing benefits cap?Yes / No

If yes, are you in receipt of the Discretionary Housing Payment?Yes / No / Not Applicable

11. Access & health

Do you require any of the following to access our services:

Interpreter - language required: / Wheelchair Access
Other (please provide details):

Do you consider yourself to have a disability?Yes / No

Do you have any long-term health conditions (including mental health)

that affects you and may restrict the type of work you are able to do?Yes / No

If you do have a disability or long-term health problem could you indicate the nature of it below:

Physical Impairment / Mental Health / Learning Difficulty
Sensory Impairment / Long standing illness/health condition / Other (Please specify below)
Please provide further details below:

12. Your skills needs

BASIC SKILLS

If English is not your first language, how well do you understand and speak English?Not very well

Fairly well

Quite well

Very well

Not Applicable

Are you able to read and complete an application form without assistance?Yes / No

Are you able to do basic sums?Yes / No

DIGITAL SKILLS

Do you have an email address?Yes / No

Do you have access to the internet at home?Yes / No

Do you have a computer or tablet that you use regularly?Yes / No

How confident are you at using computers and the internet?Not at all

Fairly confident

Quite confident

Very confident

How confident would you feel completing an online job/benefit application?Not at all

Fairly confident

Quite confident

Very confident

Would you like any help with using computers or the internet?Yes / No

EMPLOYMENT

Have you been previously employed? Yes / No

Have you undertaken any voluntary work or unpaid work placements?Yes / No

Do you feel confident in applying for jobs and attending interviews?Yes / No

Do you have any criminal convictions which may make it harder to secure a job?Yes / No

Do you have any caring responsibilities that would make it difficult to work?Yes / No

If yes, please give details:

13. Ethnicity

Asian or Asian British - Bangladeshi / Asian or Asian British – Indian / Asian or Asian British - Pakistani
Asian or Asian British – Chinese / Asian or Asian British – Vietnamese / Asian or Asian British – Other)
Black or Black British - African / Black or Black British – Somali / Black or Black British – Caribbean
Black or Black British – Other / Mixed/Dual Heritage – White and Black African / Mixed/Dual Heritage – White and Black Caribbean
Mixed/Dual Heritage – White and Asian / Mixed/Dual Heritage – OtherWhite British / White British
White Irish / White Turkish/Turkish Cypriot / White Greek/Greek Cypriot
White Gypsy/Traveller / White Irish Traveller / White European
White - Other / Other Ethnic Background / Prefer not to say

14. Sexual Orientation

Heterosexual/Straight / Gay woman/lesbian / Gay man
Bisexual / Prefer not to say

15. Religion/Belief

No religion or belief / Buddhist / Christian
Hindu / Jewish / Muslim
Sikh / Agnostic / No religion
Prefer not to say / Other

16. Other support

Have you received any training or employment support from any other organisations in the past six months?

Yes / No

If yes, please provide details:

Organisation and Staff Name / Type of Support Provided / Still Receiving Support?
Yes / No
Yes / No
Yes / No

Are you currently engaged with any other support services, or would you like to be referred to other support services?

18. How did you hear about this project?

Recommendation by friend / family member / Referred by Tower Hamlets Council
Twitter / Four Corners Email/Website
Facebook / Other (please provide details below)

Please provide details:

Have you attended a Four Corners’ course before?Yes / No

Please note: all personal and equality data that you have provided will only be used for statistical purposes by London Borough of Tower Hamlets, and all information will be held confidentially and not shared with any other organisation.

Please sign and date the Consent Form on the next page.

Consent form – sharing of information with Project Partners

To help us in tracking the outcomes of this project and to ensure that you are referred to the relevant support services offered by the Council or its partner agencies we ask that you complete this client consent form.

We ask you to check and sign this consent form to confirm that you give permission for the general information collected whilst you are participating in this project to be shared with the relevant teams and partner organisations that are involved in delivering this project

Declaration

In signing this registration form, I hereby acknowledge that I am voluntarily participating in this Access to Employment and skills training project and that:

1. I have been provided with information about this project, which explains the project aims, details of the provision and what is expected of me and have been given the opportunity to ask questions and discuss my needs.

1. I wish to register for this project and give my permission for the project to use any of the personal details I provided in order to communicate with me, by telephone, text, email or letter, unless I have provided written instructions to the contrary.

1. I understand that my details may be shared with the main project delivery partners (a list is available upon request) and that mypersonal details such as phone number, email and address details will only be passed on to other partner organisations with my consent.

1. I will inform the project if I no longer wish to receive support from the project.

1. I will inform the project if I have been successful in accessing further training or employment.

Name: / Signature: / Date:

Please return this applicationby email, post or by hand to Four Corners.

Remember to include:

1. Proof of address (Council tax bill, utility bill or similar)
2. Proof of unemployed status (e.g. JSA letter or similar)
3. Proof of other benefits claimed (e.g. Housing benefit letter or similar)
4. Please attach a CV if you have one

Four Corners, 121 Roman Road, London E2 0QN

Email:

Tel: 0208 981 6111

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