Please enable JavaScript in your browser to complete this form.11. Personal Details22. Ethnicity33. Learner Monitoring44. Work Details55. Consent A.Black Country ESF Community Grant Programme Participant Enrolment and Initial Interview RecordParticipant's NameTitle (eg Ms/Mr/Dr/etc)Forename 1Forename 2Surname / Family NameDate of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920GenderMaleMaleFemaleOtherNI NumberFull AddressAddress Line 1(flat number + flat name/house number/house name)Address Line 2(street name)Address Line 3(Village/Town/City)Address Line 4(County) Postal CodeContact Details (one number and email must be provided)Home telephone numberMobile numberEmail *Learner Eligibility 1. Participants engaged in Community Grant support must be over 16 years of age and able to take up employment in England. Please complete the relevant section below depending on if you are A) British Citizen B) EEA National or C) from a non-EEA country (one option must be complete). NationalityA) Are you a British Citizen?B) Are you a EEA national?C) Are you a non EEA national?NextCan you provide a British passport as evidence?YesNoBritish Citizen Passport * Click or drag a file to this area to upload. Other Certificate * Click or drag a file to this area to upload. ( e.g. birth certificate / adoption certificate / marriage certificate / citizens card / UK driving license / official letter)EEA Nationals- As from 1st January 2021 EEA Nationals must meet one of the following conditions holding leave to remain with permission to work granted under the new Points Based Immigration system to be eligible for ESF support: Settled Status granted under EU Settlement Scheme (EUSS)Pre-Settled Status granted under EUSSNone of the Above(Countries that belong to the EEA include Austria, Belgium, Bulgaria, Croatia, Republic of Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, and Sweden).Settled Status granted under EU Settlement Scheme Insert Code Number Pre-Settled Status granted under EUSSInsert Code NumberEUSS appliedYesNoEUSS statusGrantedDeniedInsert EUSS Code Number Please make sure a screenshot is included as evidence. Click or drag a file to this area to upload. non-EEA NationalityFor non-EEA nationals please give detailsDo you have a visa/ right to remain?YesNoEthnicityEthnic BackgroundWhiteEnglish, Welsh, Scottish, Northern Irish or BritishIrishGypsy or TravellerAny white backgroundAsian/Asian BritishIndianPakistaniBangladeshiChineseAny other Asian backgroundMixed/Multiple EthnicWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAsian or Asian BritishAny other Mixed or Multiple ethnic backgroundBlack/African/CaribbeanAfricanCaribbeanAny other Black/African/ CaribbeanOther Ethnic GroupArabAny other ethnic background Please select one option below that best describes your ethnic group or background.Do you consider yourself to have a long term disability, health problem or learning difficulty?DisabilityYesNoWhat is your primary disability, health problem or learning difficulty?disability problem *Emotional & Behavioural DifficultiesMultiple DisabilitiesMultiple Learning DifficultiesVisual ImpairmentHearing ImpairmentDisability affecting mobilityProfound complex disabilitiesSocial & Emotional difficultiesMental health difficultyModerate Learning DifficultySevere Learning DifficultyDyslexiaDyscalculiaAutism Spectrum DisorderAsperger’s SyndromeTemporary disability after illness/accidentSpeech, language, communication needsOther physical disabilityOther specific learning difficulty e.g. dyspraxiaOther medical condition (e.g. asthma, disability)Other learning difficultyOther disabilityPrefer not to sayNot provided (Please select one)PreviousNextLearner MonitoringWhat is your highest level of qualification that you have ever achieved in any subject? (GCSE/A-level/degree etc) Qualification *Level 1Full Level 2Full Level 3Level 4Level 5 and AboveOther qualifications below Level 1Entry LevelLevel 5Level 6Level 7 and AboveOther qualification, level not known(One box must be crossed)Do you lack basic skills in: EnglishYesNoMathsYesNoESOLYesNo(If foreign speaker) Household SituationDo you live in a jobless household?YesNoDo you have any dependant children in your jobless householdYesNoDo you live in a single adult household? With dependent children?YesNoAre you homeless?YesNoCommunity Grants provision supports people to improve their employment skills to help them move closer to or access the jobs market especially those within the priority groups who experience difficulties. Why do you want to access support from the Community Grants Programme?whyI want to get a jobI want to access education/ trainingI want to start looking for work (job search)I need extra support to get me ready for work (e.g. confidence building)Have you enrolled on ESF or Grants provision this academic yearEnrolled *YesNoPreviousNextEnter the last organisation you attended training withOrganisationEnter the date of your last attendanceDD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920How long is it since you last worked?Have been unemployed for less than 6 monthsHave been unemployed for 24-35 monthsHave been unemployed for 6-11 monthsHave been unemployed for over 36 monthsHave been unemployed for 12-23 monthAm not registered unemployed or was not actively looking for workBenefit StatusI am in receipt of Job Seeker’s Allowance (JSA)I am in receipt of Employment Support Allowance (ESA)I am in receipt of another state benefitI am in receipt of Universal CreditI am not claiming benefits (Economically Inactive)PreviousNext I understand this activity is part financed by the European Union through the European Social Fund (ESF) Programme 2014-2020. What is your ethnic group? Please select one option below that best describes your ethnic group or background. Where I have ticked “prefer not to say” I can confirm that I have been asked to answer the question(s) but have declined to respond. Learner Name *Signature Clear Signature Date DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920The information you provide to Walsall Community Grants Programme will be shared with the Department for Work & Pensions (DWP) and used to evaluate this project and to report to the DWP, as Managing Authority, and European Social Fund for monitoring purposes, in line with European Commission regulatory requirements. Your information will be also shared with research organisations working on behalf of the Department for Work & Pensions who may contact you to discuss your involvement in the project for research purposes. Participation in research is voluntary and you will be asked to consent before taking part in any research activity you may be contacted about. The DWP may also link your personal details to official administrative records in order to monitor your employment status before your ESF support began and 6 to 12 months after you left. This information may be also shared with research organisations working on behalf of the DWP however individuals will not be identifiable, and you will not be contacted about this research. Data will not be used or shared for any commercial or marketing purposes. At all times your information will be kept securely, and nobody will have access to it that shouldn’t. PreviousSubmit
