Train 2 Gain Form

Title MrMrsMsMiss

Firstname
Surname
Address
Town
Postcode
Telephone No
Mobile No
National Insurance No.
Sex MaleFemale

Nationality
Date of Birth
Email Address

Emergency Contact Details

Emergency Contact Name
Emergency Contact No

Do you consider yourself to have a learning difficulty, disability or health problem?
YesNo

To which social or ethnic group do you belong to
Please select ethnic group Asian or Asian British - Bangladeshi Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Any other asian background Black or Black British - African Black or Black British - Carribbean Black or Black British - Any other black background Chinese White - British White - Any other white background White - Irish Mixed - White and Asian Mixed - White and Black African Mixed - White and Black Carribbean Mixed - Any other mixed background Any other I do not wish to provide this information

Is your English your first language?
YesNo
Have you been a UK / EC / EEA resident for the last 3 years?
YesNo

Any In-house Training courses completed, please list (eg. Health and Safety)

What do you think your barriers will be during the course? (eg. time/ shift patterns)

How did you hear about the course?
SelfColleagueNotice boardFlyer at work Manager Recommended

What do you hope to gain from the course?

How confident are you about your chosen subject? – Literacy and or Numeracy (please tick)
No ConfidenceVery Little ConfidenceFairly ConfidentVery Confident