PICSWeb : Applicant Sign Up : Supported Internship

Supported Internship - Expression of Interest

CONFIDENTIAL

SUPPORTED INTERNSHIP EXPRESSION OF INTEREST FORM

PERSONAL INFORMATION

Title *

Forename *

Surname *

Address Line 1 *

Address Line 2

Address Line 3

Address Line 4

Postcode *

Home Tel No: *

Mobile No: *

DOB *

Please specify allowed method/s of contact: *

Please choose preferred method of contact: *

Email *

Have you received additional learning support at college (or during the last year of college)?

Do you have an Individual Development Plan (IDP)?

College

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):