REGISTRATION FORM - Family Mosaic

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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