Employment Skills Academy Interest Form
Please fill out this form to express your interest in the programme and help us understand your needs.
Delegate Name
*
First Name
Last Name
Delegate Date of Birth
*
-
Month
-
Day
Year
Date
Delegate's Age
*
Delegate's Email Address
*
example@example.com
Delegate's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Address (including postcode)
*
Do you identify as neurodivergent?
*
Yes
No
Prefer not to say
Please provide details of your Neurodiversity/Disability:
E.g. Diagnosed with ADHD in 2017
Emergency Contact Name:
First Name
Last Name
Emergency Contact Email:
example@example.com
Emergency Contact Telephone:
Please enter a valid phone number.
Format: (000) 000-0000.
What is your current situation?
*
Not currently working
In education or training
Working part-time
Working full-time
Other
Have you had any previous work experience?
*
Yes
No
If yes, please provide details (optional)
What would you like to gain from the programme?
*
What are your current employment goals?
*
Do you have any specific support needs or accessibility requirements?
*
What is your preferred contact method?
*
Email
Phone
Text message
Are you available to attend an 8-week programme?
*
Yes
No
Not sure
Is there anything else you would like us to know? (optional)
I understand that this is only an expression of interest and does not guarantee a place on the programme.
*
I understand
I agree to be contacted by SPACE Hertfordshire about the Employment Skills Academy programme. The programme will be delivered in partnership with Hertsmere Mencap
*
I agree
Submit Expression of Interest
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