Expression of Interest Capture Form

Expression of Interest - Your details

if you would like to express an interest to enrol but need any support completing the form or going through the Student Agreement, please call us on 07891 099460 or email us on wellbeingrec@mpft.nhs.uk

Title

First Name

Middle Name

Surname

Date of Birth

/ /

Address

Town/City

Postcode

County

Please tell us the county

Email Address

Validate Email Address

Home Telephone Number

Permission to leave an answer message on home number

Yes No

Mobile Phone Number

Permission to leave an answer message on mobile number

Yes No

Emergency Contact

Emergency Contact Name

Emergency Contact Number

Emergency Contact Relationship

About You

Primarily, in what role will you be using the Recovery College? As a:

Are you currently using any Physical Health Services outside of your GP?

Yes No

Are you currently using any Mental Health Services outside of your GP?

Yes No

How did you hear about us?

If 'other', please specify (hear about us)

Preferred Course 1

Preferred Course 2

Preferred Course 3

Other course of interest, not listed

Which locality is closest to you?

Other (locality is closest to you)

Additional Learning Needs

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

Any Additional Learning Needs

Potential ALS?

Yes No

Would you like to receive a course certificate following completion?

Yes - Digital
Yes - Paper
Yes - both
No

Equality and Diversity Monitoring

Gender

Female
Male
Prefer to self disclose (please state)

If you have indicated that you would like to self disclose your gender, please state:

Sexual Orientation:

Heterosexual or Straight
Gay or Lesbian
Bisexual
Other sexual orientation not listed
Person asked and does not know or is not sure
Not stated (person asked but declined to provide a response)
Not known (not recorded)

Ethnicity Ethnic origin categories are not about nationality, place of birth or citizenship. They are the group to which you as an individual perceive yourself to be

Nationality

If you have indicated 'other' in nationality, please state:

Religion:

If you have indicated 'other' in religion, please state:

Disability - do you consider yourself to have a disability?

Employment Status

Student Declaration

I confirm that I have read and agree to the (click on link to view) Student Agreement including the disclaimer for accessing any online courses.

Signed to agree confidentiality?

Yes No