SSA - Expression of Interest

CONFIDENTIAL

SUPPORTED SHARED APPRENTICESHIPS

EXPRESSION OF INTEREST FORM

During the Supported Shared Apprenticeship, you will have the opportunity to gain employability skills and achieve qualifications at Level 2 or above, along with valuable work experience and learning on the job.

ELITE works in partnership with a dedicated Training Provider, who will provide, assess and complete the agreed qualification with you.

You will need to be able to work 16+ hours per week to undertake this apprenticeship.

PERSONAL INFORMATION

Title *

Forename *

Surname *

Address Line 1 *

Address Line 2

Address Line 3

Address Line 4

Postcode *

Home Tel No: *

Mobile No: *

DOB

NI Number

Prefer to self-describe as (male, female, non-binary etc):

Pronouns

If other, please let us know

Please specify allowed method/s of contact: *

Please choose preferred method of contact: *

Email *

NEXT OF KIN

Next of Kin Name

Next of Kin Relationship

Next of Kin Phone

Next of Kin Email

QUALIFICATIONS

Name of your highest level of qualification

What level is this qualification?

BENEFITS

Benefit Status Indicator

TRAVEL

Has Driving Licence

Has Own Transport

Are you able to travel independently on public transport?

ELIGIBILITY INFORMATION

Employment Status

Employment History

Are you currently volunteering, work experience, paid work, EDG, WBT or have you taken part in one or more of these activities in the past. *

Details of Work Experience (if applicable)

If you are currently been in paid work please provide employer name, your job role and the number of hours worked.

Please provide details of your preferred job choices or employment sector.

Do you feel that you would be ready for paid employment within 3 month, if you were registered today?

Are you currently in paid work (if YES, the participant may not be eligible for programme)

If employed, please provide details on the number of hours worked.

Please confirm how long you have been unemployed for:

Are you currently in full time or part-time education (NB this may affect eligibility)

Are you currently in receipt of benefits

If YES, then please provide details:

Do you consider yourself to have a disability, heath condition or sensory loss:

If YES, then please provide details:

SOURCE OF REFERRAL

Primary Contractor (if applicable)

Sub-contractor (if applicable)

Title (Mr/Mrs etc):

Forename:

Surname:

Address:

Postcode:

Position:

Daytime Tel No:

ADMINISTRATOR TO COMPLETE

ELIGIBILITY CRITERIA

Age

Confirmed as Age Appropriate:

Confirmed as Geographically Appropriate:

REFERRAL ACCEPTED

Based on information above, the Advisor confirms that the participant is :

Accepted as referral to:

Reason for ineligibility:

Signposted:

Details of signposting:

PRIVACY

I confirm that the participant has been referred to a copy of ELITE’s Privacy Policy vie email/letter/ website:

Advisor Name:

First appointment booked (if applicable):

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