Expression of Interest Capture Form

Expression of Interest - Your details

Title

Preferred First Name

Surname

Date of Birth

/ /

Age at enrolment

Gender

Address

Town/City

Postcode

Has an email address

Yes No

Email Address

Validate Email Address

Landline telephone number

Mobile telephone number

If you are under 18, are your parents/carers aware of your enrolment at the College?

Yes No

If you are under 18 and we are unable to contact you regarding your enrolment at the College, are you happy for us to speak with your parent/carer?

Yes No

Emergency Contact

Emergency Contact Name

Emergency Contact Number

Emergency Contact Relationship

Your chosen course(s) / workshop(s)

Preferred Course 1

Preferred Course 1 Start Date

What would you like to achieve from attending course 1

Preferred Course 2

Preferred Course 2 Start Date

What would you like to achieve from attending course 2?

Preferred Course 3

Preferred Course 3 Start Date

What would you like to achieve from attending course 3

Your single preferred location

Background Information

This information is for monitoring purposes only and will be kept confidential. Please tick all that apply.

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

Someone who is/has used mental health services

Currently
Previously

Friend/family/carer of someone who uses mental health services

Currently
Previously

And do you belong to another group as well?

A SWYPFT member of staff
A staff member from another service
Other (please specify)
Prefer not to say

Individual and learning needs

The Recovery College is committed to supporting all of our learners. Please tell us you have any specific support or learning requirements that you think we should be aware of and how we can help with these. These may include, but are not limited to, large print course materials, level building access, extra breaks, one to one support to help to work towards your learning plan.

Which of the following statements do you identify with?

Please help us to identify your mental health needs with a brief description of the challenges you have faced or may be addressing through current contact with mental health services:

Please tell us more so that we can better support you

Any Additional Learning Needs

How did you hear about us?

If 'other', please specify (hear about us)

Equality and Diversity Monitoring

Which category below best describes your ETHNICITY?

What is your main language?

English
Other (including sign languages) please specify

Other (language)

Which category below best describes your RELIGION or BELIEF?

Other Faith Affiliation

Please specify 'other' disability

Gender

Female
Male
Live in a gender other than assigned at birth
I prefer not to say

What is your sexual orientation?

If other please specify (sexual orientation)

Caring Responsibilities

Yes No

Have you had a baby in the last twelve months?

Yes No

Employment Status

Recovery College Charter

The Recovery College aims to create an environment that encourages learning and where students feel they are supported. This charter is designed to help students to understand what is expected from you and of us, whilst accessing the college.

What you can expect from us:

We will respect you as an individual at all times. We will do this by:

Respecting your values, opinions and beliefs
Equality of opportunity, free of harassment and discrimination
Helping people that support you to access courses e.g. a career, friend or interpreter
Behaving in a way that fosters a shared understanding and mutual respect
Encouragement to take responsibility for your own learning and development
Opportunities for you to comment on and review the courses and facilities on offer
Clear information about the courses on offer
The chance to celebrate success
Suitably trained facilitators and volunteers who are committed to the quality of your experience and to their own professional development

What we expect from you:

Respect the rights, choices, beliefs and opinions of others
Commit to attending course/workshop you have enrolled on
Do my best to inform the college ahead of time, if I am going to be late or miss a session and return from my breaks in a timely manner
Respect the college environment and equipment
Ensure mobile phones are on silent/turned off before entering any learning area
If I act in a way that may put myself or others at risk, I understand I may be asked to leave the course
Avoid the use of language or terminology that might offend others
Do not attend the college if under the influence of alcohol or substances, because if affects my ability to learn and/or ability to conduct myself respectfully.
I agree to behave appropriately within the learning environment and accept guidance from the course facilitator
Keep us informed of any special needs or requirements you have so we can support you in the best way possible
Seek early advice and support whenever you need clarification, or if you have a problem
I will keep any personal/private information heard during any course strictly confidential

By filling out this form and enrolling on these courses, I am confirming that I will attend these courses and abide by the College's code of conduct. I understand that failure to attend these courses without contacting the Recovery College beforehand may result in a period of time where I am unable to attend any courses that I have enrolled on or was planning to enrol on. I also understand that if I am in danger, or there is a risk to myself or others, the information that I have given may be shared with others to ensure everyone's health and safety. We shall let you know if we have to share this information.