1Referral2Participant Details3About You4Equality5Privacy Referral SourceWho is completing this form? I am completing this form for myself (self-referral) I am completing this form on behalf of someone else What is your relationship to the participant? I’m a parent / guardian / relative / friend I’m a professional working with this person Name of referrer Referrer Phone Number Referrer Email Address Name of Organisation? (eg. Temple St Job Centre, BCC team, FE College) Organisation Phone Number Organisation Email Address Participant DetailsFirst Name Surname Pronouns Date of Birth Day Month Year Address Postcode Phone Number Email Address About YouYour right to live and work in the UKWhat is your nationality?Select an optionAfghanAlbanianAlgerianAmericanAndorranAngolanAnguillanCitizen of Antigua and BarbudaArgentineArmenianAustralianAustrianAzerbaijaniBahamianBahrainiBangladeshiBarbadianBelarusianBelgianBelizeanBenineseBermudianBhutaneseBolivianCitizen of Bosnia and HerzegovinaBotswananBrazilianBritish British Virgin IslanderBruneianBulgarianBurkinanBurmeseBurundianCambodianCameroonianCanadianCape VerdeanCayman IslanderCentral AfricanChadianChileanChineseColombianComoranCongolese (Congo)Congolese (DRC)Cook IslanderCosta RicanCroatianCubanCymraesCymroCypriotCzechDanishDjiboutianDominicanCitizen of the Dominican RepublicDutchEast TimoreseEcuadoreanEgyptianEmiratiEnglishEquatorial GuineanEritreanEstonianEthiopianFaroeseFijianFilipinoFinnishFrenchGaboneseGambianGeorgianGermanGhanaianGibraltarianGreekGreenlandicGrenadianGuamanianGuatemalanCitizen of Guinea-BissauGuineanGuyaneseHaitianHonduranHong KongerHungarianIcelandicIndianIndonesianIranianIraqiIrishIsraeliItalianIvorianJamaicanJapaneseJordanianKazakhKenyanKittitianCitizen of KiribatiKosovanKuwaitiKyrgyzLaoLatvianLebaneseLiberianLibyanLiechtenstein citizenLithuanianLuxembourgerMacaneseMacedonianMalagasyMalawianMalaysianMaldivianMalianMalteseMarshalleseMartiniquaisMauritanianMauritianMexicanMicronesianMoldovanMonegasqueMongolianMontenegrinMontserratianMoroccanMosothoMozambicanNamibianNauruanNepaleseNew ZealanderNicaraguanNigerianNigerienNiueanNorth KoreanNorthern IrishNorwegianOmaniPakistaniPalauanPalestinianPanamanianPapua New GuineanParaguayanPeruvianPitcairn IslanderPolishPortuguesePrydeinigPuerto RicanQatariRomanianRussianRwandanSalvadoreanSammarineseSamoanSao TomeanSaudi ArabianScottishSenegaleseSerbianCitizen of SeychellesSierra LeoneanSingaporeanSlovakSlovenianSolomon IslanderSomaliSouth AfricanSouth KoreanSouth SudaneseSpanishSri LankanSt HelenianSt LucianStatelessSudaneseSurinameseSwaziSwedishSwissSyrianTaiwaneseTajikTanzanianThaiTogoleseTonganTrinidadianTristanianTunisianTurkishTurkmenTurks and Caicos IslanderTuvaluanUgandanUkrainianUruguayanUzbekVatican citizenCitizen of VanuatuVenezuelanVietnameseVincentianWallisianWelshYemeniZambianZimbabweanDo you have right to work in the UK? Yes, I am a EU, EEA, Swiss citizen with settled/pre-settled status Yes, I have a permanent residence in the UK (indefinite leave to remain) Yes, I have other visas that allow me to work Yes, I have a refugee status (with permission to work) Yes, I have a permanent residence in the UK (indefinite leave to remain) No / Other Other: Please bring in your birth certificate or passport to your initial meeting. If you’re not British, please bring in your proof of ‘right to work’ in UK, such as visa, biometric identity card or EUSS code.Your Employment StatusWhat is your employment status (on joining)? Employed Unemployed Details of your employment Facing redundancy Zero hours contract / casual work contract Self-employed Other Other Please select one option that best describes your current employment status: Unemployed- short term (6 months or less) Unemployed- long term (6 months+) Full time student or in training I have full (35 hours per week+) caring responsibilities for a dependent child age 2 or younger I have full (35 hours per week+) caring responsibilities for a family member None of the above Please provide the name of your training provider or educational establishment: Please explain your current employment situation: Your BenefitsAre you receiving any benefits or financial support? Yes No Please select all of the benefits you are receiving: Universal Credit (UC) Employment and Support Allowance (ESA) Job Seeker's Allowance Disability Living Allowance Other - (e.g. Personal Independence Payment, financial support from family, redundancy pay-out, other private income source) How long have you been receiving Universal Credit? 6 months or less More than 6 months More than 12 months Do you have a Job Centre Plus worker? (Work Coach / Disability Employment Advisor) Yes No I'm not sure Name of Job Centre Plus Worker? Email address of Job Centre Plus Worker? Are you in a Limited Capability for Work (LCW) or Limited Capability for Work and Work Related Activities (LCWRA) group?The Work Capability Assessment is used to decide whether or not you are fit for work for ESA and Universal Credit'. Yes No I'm not sure Please specify the benefits you are receiving: Your entitlement to benefits could be affected by decisions you take, or changes and progress you make while or after engaging with the We Work for Everyone programme. It is vital to inform all relevant agencies about any changes to your work hours and pay, even if you think your benefits will not be affected. It is your responsibility to inform all relevant agencies of changes to your circumstances, although your Navigator can support you with this process if needed.Your EducationWhat is your highest level of educational attainment (on joining)? No Formal Qualification /below primary level education NVQ Level 1 (e.g. GCSEs Grades D-G or 3-1 ) NVQ Level 2 (e.g. GCSEs Grades A*-C or 9-4) NVQ Level 3 (e.g. A Levels) NVQ Level 4 (Certificates of higher education) or over Do you have any other qualifications? Is English your first or main language? Yes No Please specify your main language: Household informationAre you from a jobless household?‘Jobless household’ refers to all household members irrespective of age (e.g. a young person living with retired grandparents would count as living in a jobless household) Yes No Prefer not to answer Are you from a jobless household with a dependent child or children?‘Jobless household’ with dependent children’ is a sub category of ‘jobless household’, meaning that anyone falling into this category must also be recorded under jobless household. ‘Dependent child / children’ means individuals aged 0-17 years OR individuals aged 18-24 if economically inactive and living with at least one parent. Yes No Prefer not to answer Are you a single parent / carer?‘Single adult household with dependent children’ includes only one adult (individual aged 18+) irrespective of their employment status. Yes No Prefer not to answer Are you homeless?A person will be classed as being legally homeless if they: have no home in the UK or anywhere else in the world; have no home where they can live together with their immediate family; can only stay where they are on a very temporary basis; do not have permission to live where they are; have been locked out of their home and are not allowed back; cannot live at home because of violence or abuse or threats of violence or abuse which are likely to be carried out against them or someone else in their household; it is not reasonable for them to stay in their home for any reason, for example, their home is in very poor condition; cannot afford to stay where they are. Yes No Prefer not to answer Are you an ex-offender?Ex-offender: a person who has one or more previous criminal convictions. Ex-offenders will have completed all supervision and licence requirements. Yes No Prefer not to answer EqualityBackground We want to make sure that our services are fair and provided to those who need them. The information you provide will be used to help us to plan your support. By answering these questions, you will help us improve what we do and make our services more accessible. If you do not wish to answer any questions below, please select ‘prefer not to answer’. Ethnic BackgroundSelect an optionWhite – BritishWhite – IrishWhite – other EUTraveller / GypsyWhite – Other (please specify)Mixed – White and Black CaribbeanMixed – White and Black AfricanMixed – White and AsianSouth Asian or Asian British – IndianSouth Asian or Asian British – PakistaniSouth Asian or Asian British – BangladeshiSouth Asian or Asian British – OtherChineseBlack or Black British – CaribbeanBlack or Black British – AfricanBlack or Black British – OtherOther (please specify)Prefer not to sayOther Ethnicity: DisabilityWould you class yourself as disabled? Yes No Prefer Not to answer Visually Impaired/ Blind Yes No Prefer Not to answer Hearing Impaired / Deaf Yes No Prefer Not to answer Mental Health Issues Yes No Prefer Not to answer Learning Difficulty Yes No Prefer Not to answer Autism Spectrum Disorder/Asperger’s Yes No Prefer Not to answer Other Physical Disability Yes No Prefer Not to answer Other work limiting illness or condition PrivacyObtaining/disclosing information(Required) I understand that my personal information will be held by WE Work for Everyone, and that it may be shared with referral organisations only with my permission* I understand that WE Work for Everyone and partner organisations may contact me for evaluation purposes (satisfaction survey) * By signing this form, you: Have been informed and understand that the activity delivered by the provider named on this form is part-funded by the European Social Fund and have received leaflet ESF2020 Understand that this ESF Provision is voluntary. Agree to participate in this ESF Provision. Understand that WE Work for Everyone will store your basic personal information included on this form, to make referral to the Provider. Understand that, if eligible, you will meet navigators to receive 1-2-1 support best tailored to you from our single menu of opportunities. Understand that, our staff may refuse to support those who behave in a discriminatory, offensive, aggressive or disruptive manner. Give consent for us to stay in touch with you to monitor your progress and provide support for up to 6 months from when you join a training programme or employment. You can choose any mode of communication you prefer – a phone call, SMS, Email or by post. You can opt out of staying in touch after 6 months. Open EasyRead Participant Agreement I have read and accept the Participant Agreement above(Required) I confirm that I have read and accept the Participant Agreement I understand and accept the commitment expected of me while engaging with the programme:Your name(Required) First Date of Signing(Required) Day Month Year SignatureIf you are unable to use the signature box, leave it blank and we will help you at your first meeting. EmailThis field is for validation purposes and should be left unchanged.
