Employment Skills and confidence
Please fill out this form to express your interest in the programme
Your Name
*
First Name
Last Name
Your Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Your Age
*
Your Email Address
*
example@example.com
Home Address (including postcode)
*
Your phone number
*
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 and conficence programme. The programme will be delivered in partnership with Hertsmere Mencap
*
I agree
Submit Expression of Interest
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