subject_line
Building Growth South West Client Enrolment Form
Title:
*
Mr
Mrs
Ms
Miss
Other
Other
First Name
*
Last Name
*
Phone Number
*
Email Address
*
Street Address
*
Address Line 2
City
*
County
*
Post Code
*
Age range
*
18–24
25–29
30–34
35–39
40–44
45–49
50–54
55–59
60–64
65 or over
Prefer not to say
Gender
*
Male
Female
Transgender
Other
Prefer not to say
Ethnicity
*
🛈
White British
White Irish
White Other
Chinese
Mixed White & Asian
Mixed White & Black Caribbean
Mixed White & Black African
Black or Black British-Caribbean
Black or Black British-African
Black or Black British-Other
Asian or Asian British-Pakistani
Asian or Asian British-Bangladeshi
Asian or Asian British-Indian
Asian or Asian British-Other
Prefer not to say
Other
Other
Do you consider yourself to have a disability?
*
Yes
No
Prefer not to say
Do you have easy access to the internet?
*
Yes
No
How did you hear about us?
*
Social Media
Leaflet
Event
Word of mouth
Referral
Newsletter
Website
Other (please specify)
Other (please specify)
If you selected Social Media please specify which channel
*
Facebook
Instagram
Twitter
Linkedin
I can confirm that none of my staff are currently engaged in duplicate ESF activities as learners
*
Yes
No
I have received and understand the Client Eligibility Guide and I confirm that I am not a business in difficulty as defined by 2.1 of the Community Guidelines and State Aid for Rescuing and Restructuring Firms in Difficulty (2014/C249/01) as of 31st December 2019
*
Yes
No