Expression of Interest Capture Form

Expression of Interest - Your details

Your Personal Details

Title

First Name

Middle Names

Surname

Date of Birth

/ /

Address

Town/City

Postcode

Has an email address

Yes No

Email Address

Validate Email Address

Home Telephone Number

Permission to leave an answer message on home number

Yes No

Mobile Phone Number

Permission to leave an answer message on mobile number

Yes No

Preferred method of contact

Email
Phone
Text/SMS
Post

Preferred time of contact

Mornings
Afternoons
Evenings
Anytime

About You

Primarily, in what role will you be using the Recovery College? As a:

Have you ever/ are you experiencing mental health difficulties?

Yes No

Please provide details of any relevant care coordinators/named workers that you are working with along with the service they provide and a contact number

How did you find out about us?

Preferred Courses

Preferred Course 1

Preferred Course 2

Preferred Course 3

Any other topics you may be interested in

Additional Learning Needs

I am interested in discussing one or more of the following adjustments before I attend my Recovery College course:

Use of stressballs, fidget items, distraction items (for emotional regulation)
Adjustments to written material
Additional support with reading and / or-writing
Use of colour overlays
Interpreter

Is English your first language?

Yes No

Any Additional Learning Needs

Emergency Contact Details We need to have an emergency contact number in order to process your registration form.

Emergency Contact Full Name

Emergency Contact Number

Emergency Contact Relationship

Equal Opportunities Monitoring

The Thurrock Recovery College collects information from students on key characteristics which can be related to providing equal opportunities for all. The information collected will remain confidential.

Gender

What are your preferred pronouns?

How would you identify your sexual orientation?

What is your marital status?

Ethnicity

Nationality

Religious Belief

Other Religious Belief

Do you consider yourself to have a disability?

Yes No Prefer not to say

Employment Status

Student Declaration

Having an unspent relevant criminal conviction does not automatically mean that you will be unable to access a course with the Thurrock Recovery College, however the staff team within the college will meet to discuss your application

Please indicate whether you have any unspent 'relevant' criminal convictions. Relevant unspent criminal convictions being those against a person (whether violent or sexual), and offences involving drugs or controlled substances.

Yes No

Please mark in the box if you would prefer not to be notified by email of spaces available on courses running.

I have read and understood the confidentiality and information sharing information