Learner Agreement Form
First Name
*
Surname
*
Email Address
*
example@example.com
Gender
*
Please Select
Male
Female
Other
DOB
*
-
Day
-
Month
Year
Date
National Insurance Number
*
Ethnicity
*
Please Select
31. English (Welsh/Scottish/Northern Irish/British)
32. Irish
33. Gypsy or Irish Traveller
34. Any other White background
35. White and Black Caribbean
36. White and Black African
37. White and Asian
38. Any other mixed, multiple ethnic background
39. Indian
40. Pakistani
41. Bangladeshi
42. Chinese
43. Any other Asian background
44. African
45. Caribbean
46. Any other Black, African, Caribbean background
47. Arab
98. Any other ethnic group
ZZ. Prefer not to say
Phone Number
*
Postcode
*
Address
*
Do You Consider Yourself To Have A Disability / Health Problem / Learning Difficulty
*
Yes
No
If Yes, select from the list
*
Dyslexia
Dyscalculia
Dyspraxia
Other Learning Difficulty
Autism Spectrum Disorder
Aspergers Syndrome
Visual Impairment
Hearing Impairment
Disability Affecting Mobility
Other Physical Disability
Other Medical Condition
Mental Health Difficulty
Temporary Difficulty After Illness
Allowed Methods Of Contact
*
Please Select
Phone
Email
Letter
Employment Status
*
I am employed
I am not employed
Employment Status
*
Self Employed
Employed less than 16 hours a week
Employed 16-19 hours a week
Employed 20 hours or more a week
Earn less than £27,040.00 per year
Employer First Name
*
Employer Surname
*
Company Name
*
Job Title
*
Employer Postcode
*
Employer Address
*
Unemployment Status
*
Unemployed less than 6 months
Unemployed 6-11 months
Unemployed 12-23 months
Unemployed 24-35 months
Unemployed over 36 months
Benefit Type
*
JSA
UN CR
ESA
Other State Benefit
House Hold Situation
*
Please Select
1. No household member is in employment and the household includes 1 or more dependant children
2. No household member is in employment and the household does not include any dependant children
3. Learner lives in a single adult household with dependant children
99. None of the above applies
98. I do not wish to answer this question
Emergency Contact Name
*
Emergency Contact Number
*
Is The UK Your Country Of Birth
*
Yes
No
What Was The Date Of Your Arrival In The UK / EU / EEA
*
-
Day
-
Month
Year
Date
What Is Your Country Of Birth
*
Which Country Issues Your Passport
*
Are You An Asylum Seeker
*
Yes
No
Do You Have Refugee Status
*
Yes
No
Do You Have The Right To Abode In The UK
*
Yes
No
Do You Give Consent For The Collection And Use Of Personal Images For DTN Media
*
Yes
No
H&S, Privacy Notice And Information On How Personal Data Is Stored Is Available Upon Request
*
LRS, Learner Records Service Is Used To Access Learners Previous Qualifications To Ensure Eligibility Of Funding
*
Do You Agree For DTN To Share Progress Information With Prospective Employers To Support You In Your Search For Employment
*
I Agree
I Do Not Agree
Do You Have Any Previous Convictions
*
Yes
No
Learner Declaration - I have Completed This Form To The Best Of My Knowledge And Understand If I Have Declared False Information, DTN Academy May Take Action Against Me To Reclaim Any Tuition Fees And Any Funding That May Have Been Incorrectly Claimed
*
Date Completed
*
-
Day
-
Month
Year
Date
Submit
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