REGISTRATION FORM - Family Mosaic

REGISTRATION FORM
SECTION 1 (Please print)
Are you Family Mosaic Housing Association Resident/Customer?
Yes No other (please state) _____________________________
Would you consider moving to another area if you secured work? Yes
No
Are you a supported housing resident? Yes
No
If Yes, name of support worker _____________________________
First name:
Surname:
Address:
_____________________________
_____________________________Title Mr Mrs Miss Ms (please circle)
________________________________________________________
_________________Postcode_____________Borough/District:___________________
Telephone:_________________________Mobile: _________________________
Email:
________________________________________________________
SECTION 2
Please tick your ethnic origin:
WHITE
British
Irish
Other
If other please specify _______________
BLACK (Incl. British)
African
Caribbean
If other please specify _______________
CHINESE (Incl. British)
Chinese
If other please specify _______________
What is your first language?
ASIAN (Incl. British)
Bangladeshi
Indian
Pakistani
If other please specify_______________
MIXED BACKGROUND
White and Black Caribbean
White and Black African
White and Asian
If other please specify _______________
NOT DECLARED
___________________________________________
If you speak any other languages, please specify: _________________________________
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SECTION 3
Are you:- Employed Yes No
If unemployed please indicate period of unemployment
Under 6 month 6 - 12 months 12 – 18 months ‎18‎ٱ months+
Are you currently in receipt of benefits (e.g. Job Seekers Allowance, Employment Support
Allowance, Income Support, Incapacity Benefit or Disability Living Allowance)?
_____________________________________________________________
Do you feel confident with the following in everyday situations?
Reading: Yes No Writing: Yes No Maths: Yes No
Yes No Yes No Yes No
SECTION 4
Do you know how to use a computer? Yes No
Are
Would
you
you
a lone
like
parent?
training? Yes No
Yes No
Are you a refugee? Yes No
Are you an asylum seeker? Yes No
Are you homeless? Yes No
Have you ever had a problem with drugs/alcohol? Yes No
Have you had contact with the probation service in the last 2 years? Yes No
If yes please give details: _________________________________ ______
____________________________________________________________________
____________________________________________________________________
SECTION 5
Do you have a disability (mental or physical)? Yes No
Do you have any support needs? Yes No
If yes please state: _________________________________________________________
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SECTION 6
Please tick all areas of work you are interested in.
Administration Reception Customer Service
Care Worker Childcare Bar Work
Construction Data Entry Driving
Gardening Hotel Computing & IT
Restaurant Retail Languages
Security Warehouse Sales
Self-Employed
Other………………………………………………………..…….
If you have expressed an interest in Administration Work, what is your typing speed (if known)
WPM?: _______________________
Are you looking for full time work, or would you consider either:-
(Please tick)
Self-employed Part-time Full-time Either
If you are looking for specific hours of work please give more information here
___________________________________________________________________
SECTION 7
If you are training/studying, please complete the following section:
Start Date of Course: ____/____/_____ End Date of Course:____/_____/_____
Subject/Course Title:__________________________________________________________
Level: ________________________ Qualification:__________________________________
Do you have a NVQ level qualification? If so what level is it?
0 1 2 3 4 5
Equivalent to: CSE 5 GCSEs 2 A Levels 1 st Degree Higher Degree
(A-C)
Please state any other qualifications you have __________________________________
__________________________________________________________________________
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SECTION 8
Do you require assistance is finding suitable childcare? Yes No
Declaration Data Protection Act 1998
All details we receive from you will be stored on a database. Access to the information will be strictly
regulated – the people who access this information will normally be only Pathways2work staff and the
database officers themselves. Possible other people the database might be passed on to are as follows:
Funders who wish to audit what we report to them
We have to track who we give help to and report this. They may want to check we are telling the truth.
Local Training providers
This only happens if you asked us to look for training for you. We would pass mailing details and other
information relevant for them to assess your suitability for their course.
Childcare providers
This only happens if you asked us to look for childcare for you. We would pass mailing details and other
information relevant for arranging childcare.
Basic Skills support providers
This only happens if you said you would like help with English or numeracy. Again, only information with
relevance would be given.
Job Centre Plus
Confirmation of your registration with pathways2work and confirmation that you have found employment
may be shared with Job Centre Plus. Again, only relevant details will be passed on.
Please note that your information will not be used in any way than as described on this sheet, or passed
on to anyone not mentioned here.
This Registration Information must now be attached to the Client Enquiry form (if the two have not
already been completed at the same time) and entered on database.
Client Signature
Print Name
_____________________________________________
_____________________________________________
Employment Liaison Officer Signature _____________________________________________
Print Name
Date
_____________________________________________
___/____/____
You have the legal right to inspect the data that is held about you. If you wish to exercise this right, you
should write to: Employment & Skills Development Manger, Social & Financial Inclusion, 20 Queen
Elizabeth Street, Southwark, SE1 2RJ; Tel: 020 7089 1336
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