Online registration form - Recovery College

First Name(s)*

Surname*

Date of birth*

Email Address*

Home Address*

Street Address Address Line 2 Town Post Code Country

Telephone Number*

What is your preferred method of contact?*

Phone

Do you give permission to leave an answer message on your phone number?*

Yes

What is your preferred time of contact?*

Emergency Contact Details

Name*

Contact Number*

Accessibility

Primarily, what role will you be using the college for?*

Have you ever, or are you experiencing mental health difficulties?*

Are you accessing the Inclusion Thurrock Service?*

If yes, please fill out the name of your Talking Therapy named worker

If yes, please provide details of any relevant care coordinators/named workers you are working with

Please provide their name, service and telephone number

Is English your first language?*

If you indicated that English is not your first language, do you feel that you need assistance in understanding the course content?

Yes

If you have any learning disabilities (such as hearing of visual impairment) or medical conditions (such as epilepsy or diabetes), please state them in the box below.

Employment Status*

Employed

Volunteering

Full-time education / training

Unemployed

Long term sick / Disabled

Off sick from work/ Statutory Sick Pay

Full-time homemaker, parent or carer

Retired

Course

How did you hear about us? Please select most appropriate.*

If you selected 'other', please state below

Let us know your preferred course(s) of interest

Please write all courses you'd like to join.

What is your time preference?*

Morning

Afternoon

Evening

Please select all locations you may be able to attend*

Online

Grays

Tilbury

South Ockendon

Chadwell

Purfleet

Stanford-le-Hope

Equal Opportunities Monitoring

What is your sexual orientaion*

Bisexual

Gay

Heterosexual

Other

Prefer not to say

Gender*

Male

Female

Prefer not to say

Other

What is your ethnicity*

Ethnic origin categories are not about nationality, place of birth or citixenship. They are the group/s to which you as an individual percieve yourself to be.

What is your marital status*

Single

Married

Civil Partnership

Widow/Widower

Divorced

Prefer not to say

Nationality*

Religious Belief*

Do you consider yourself to have a disability?*

Student Declaration

Criminal Convictions*

Please indicate whether you have any unspent relevent criminal convictions. Relevent upspent criminal convictions being those against a person (whether violent or sexual), and offences involving drugs or controlled substances. Having an unspent relevent criminal conviction does not automatically mean that you will be unable to access a course within Recovery College, however the staff within the Recovery College will meet to discuss your application.

By ticking the below, I agree to adhere to the student agreement terms and conditions*

I agree

*Please read the terms and conditions below, before ticking this box

Signed*

Date*

Do you want to enrol with Inclusion Thurrock Recovery College? Are you interested in taking part in our courses? Submit an online registration form below!

Registration Form

Emergency Contact Details

Accessibility

Course

Equal Opportunities Monitoring

Student Declaration