BCHA Learn Online Enrolment Form

Please tick the courses or projects that you are interested in:

All Being Well (Wellbeing Course)

Essential Support Work Skills (Level 1)

Food for Life

Horticulture (Level 1) [City & Guilds]

Horticulture (Level 2) [City & Guilds]

Digital Life Skills

Skills for Work

Right At Home (Tenancy Training)

Do you have any allergies or dietary requirements (e.g. vegetarian)?: *

First name: *

Surname: *

Date of birth: *

Day

Month

Year

National Insurance Number: *

Address line 1: *

Address line 2:

Town/City: *

Postcode: *

Phone: *

Email: *

Ethnicity:

Please Select

Gender:

Pronouns:

Are you a BCHA Tenant? *

Yes

No

Are you currently in receipt of Universal Credit? *

Yes

No

Are you currently working? *

Yes

No

Are you currently in education or training? *

Yes

No

Are you a UK citizen? *

Yes

No

Have you been a permanent resident in the UK for the last 5 years? *

Yes

No

If you have selected ‘No’ to either of these questions you will need to provide evidence of your residency (e.g. passport, biometric residency card, share code) at enrolment.

Emergency Name: *

Emergency Number: *

Emergency Relationship: *

Do you have any learning disabilities, mental and/or physical health conditions? *

Yes

No

Please explain in detail: *

Do you have any pending criminal trials, unspent convictions, licence, court orders, restrictions or any other relevant information that we need to be aware of? It is essential that full details are provided, this includes providing contact details for your probation officer or offender manager, if applicable. Providing full details will help us process your referral quickly. *

Yes

No

Please explain in detail: *

If there is anything else that you would like us to be aware of, please let us know:

What is your preferred method of contact? *

Please Select

Referrer name and role:

Referral company:

Referral contact details:

BCHA Website

Word of Mouth

BCHA Learn Poster

Support Worker (please state service)

Other (please state)

Please provide information: *

Please ensure this form is fully completed and signed, as we will not be able to proceed without certain information. Once received, we will contact you to arrange enrolment. *

Please fully read BCHA’s Privacy Notice before signing, by signing this document, I agree with BCHA’s Privacy Notice and give consent for BCHA to share any of the above information with third parties if a risk is disclosed and that we may give details to the referrer regarding your attendance at the course/s referred for.

If a referral partner has completed this form, then consent must be agreed prior to the form being shared with BCHA Learn. *

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BCHA Learn Enrolment Form

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Important Client Information

Referral Information (if applicable)

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