Welcome to Spear v1
First Name
Last Name
Known as
Gender
Male
Female
Other
Prefer not to say
Date of Birth
Please select the right date of birth in the calendar
Mobile Number
Please enter Mobile Number prefixed with 0
Email Address
Home PhoneNumber
Mailing Address - Number/Street Name
Mailing Address - City/Village
Mailing Address - County
Mailing Address - Postcode
City
Please select...
Bournemouth
Brighton
Bristol
Leeds
London
Preston
Cheltenham
Borough
Please select...
All Saints
Battledown
Benhall and The Reddings
Charlton Kings
Charlton Park
College
Hesters Way
Lansdown
Leckhampton
Oakley
Park
Pittville
Prestbury
Springbank
St Mark's
St Paul's
St Peter's
Swindon Village
Upper Hatherley
Warden Hill
Preston
East Sussex
West Sussex
Blandford
Bournemouth
Christchurch
Dorchester
New Forest
Other
Poole
Purbeck
Weymouth
Wimborne
Adel & Wharfedale
Alwoodley
Ardsley & Robin Hood
Armley
Beeston & Holbeck
Bramley & Stanningley
Burmantofts & Richmond Hill
Calverley & Farsley
Chapel Allerton
Cross Gates & Whinmoor
Farnley & Wortley
Garforth & Swillington
Gipton & Harehills
Guiseley & Rawdon
Harewood
Headingley & Hyde Park
Horsforth
Hunslet & Riverside
Killingbeck & Seacroft
Kippax & Methley
Kirkstall
Little London & Woodhouse
Middeton Park
Moortown
Morley North
Morley South
Otley & Yeardon
Pudsey
Rothwell
Roundhay
Temple Newsam
Weetwood
Wetherby
Outside Leeds
Avonmouth
Bedminster
Bishopston
Bishopsworth
Brislington
Clifton
Cotham
Easton
Eastville
Filwood
Frome Vale
Hartcliffe and Withywood
Henbury and Brentry
Hengrove and Whitchurch Park
Hillfields
Horfield
Hotwells and Harbourside
Kingswood
Knowle
Lawrence Hill
Lockleaze
Redland
Southmead
Southville
St George
Stockwood
Stoke Bishop
Westbury-on-Trym and Henleaze
Windmill Hill
Barking and Dagenham
Barnet
Bexley
Brent
Bromley
Camden
Croydon
Ealing
East Sussex
Enfield
Greenwich
Hackney
Hammersmith and Fulham
Haringey
Harrow
Havering
Hillingdon
Hounslow
Islington
Kingston upon Thames
Lambeth
Lewisham
Merton
Newham
Redbridge
Richmond upon Thames
Royal Borough of Kensington and Chelsea
Southwark
Stoke Newington
Sutton
Tower Hamlets
Waltham Forest
Wandsworth
Westminster
West Sussex
Slough
Emergency Contact Name
Emergency Contact Relationship to you
Emergency Contact- Phone Number
How did you find out about Spear before attending today?
Please select...
Met in Job Centre
Referred by Job Centre
Referred by other organisation
Recommended by a friend/family member
Saw a flyer/poster
Online Advert - facebook
Online Advert - google ad
Other
Ethnicity
Please select...
Bangladeshi
Chinese
Indian
Pakistani
Other Asian
Mixed - White and Asian
Mixed - White and Black African
Mixed - White and Black Caribbean
Mixed Ethnicity
Black African
Black Caribbean
Other Black or Black British
White British
White Irish
White Gypsy/Irish Traveller
White other
Middle Eastern
Other
Black British
Asian/ Asian British
Black/ African/ Caribbean/ Black British
Mixed/ multiple ethnic groups
White
Other Ethnic Group
Are you a British Citizen?
Yes
No
If No, What is your nationality?
Do you have the right to work in the UK?
Yes
No
What is your Visa Status?
Please select...
N/A
Asylum Seeker
Right of Abode
Student Visa
Visitors Visa
Work Visa
Other
Indefinite leave to remain
Refugee
Settled Status
What proof of eligibility to work can you provide?
For example, National Insurance Number.
National Insurance Number
The NI Number should be in the below format: AB123456C (2 Letters followed by 6 numbers and a letter)
Do you claim any benefits? If so, which ones?
Not Claiming
Carer's Allowance
Child Tax Credit
Council Tax
Disability Living Allowance
Employment and Support Allowance
Family Credit
Housing Benefit
Income Support
Job Seekers Allowance
Local Authority Subsistence Allowance
Training Allowance
Universal Credit
Other
Which Job Centre do you attend?
Please select...
Acton
Albion Street
Barking
Barnsbury
Bedminster Job Centre
Bexhill
Bexley Heath
Bishopworth
Blackfriars
Blandford
Bournemouth
Brighton
Brixton
Broad walk Job Centre
Bromley
Cheltenham
Chichester
City Tower
Clapham Common
Crawley
Croydon
Dalston
Dartford
Ealing
Eastbourne
Eastgate
Eltham
Enfield
Finsbury Park
Forest Hill
Fulham
Guiseley
Hackney
Hammersmith
Harlesden
Harrow
Hastings
Hayes
Haywards Heath
Hendon
Highgate
Horfield Job Centre
Horsham
Hounslow
Hove
Hoxton
Hythe
Kennington Park
Kentish Town
Kilburn
Kings Cross
Kingston
Leeds Park Place
Leeds Southern House
Lewes
Lewisham
Leytonstone
Lisson Grove
London Bridge
Marylebone
Mitcham
Morley
Newhaven
None
North Kensington
Palmers Green
Peckham
Poole
Poplar
Pudsey
Purley
Putney JCP
Queens Park
Redbridge
Ringwood
Romford
Seacroft
Shepherds Bush
Southall
Stockwell
Stratford
Streatham
Sutton
Temple Street Job Centre
Thornton Heath
Tottenham JCP
Twickenham
Uxbridge
Walthamstow
Wandsworth
Wembley
Westminster
Weymouth
Willesden
Wood Green
Woolwich
Worthing JCP
York road
Youth Hub at The Galleries
Who is your Job Centre Work Coach?
When did you sign on at the Job Centre?
When was the last time you were in work or education?
Please select...
Currently in work/education
0-3 months ago
3-6 months ago
6-12 months ago
1-2 years ago
2+ years ago
How many hours per week do you work or study?
Please select...
1-7
8-15
16+
N/A
Which School(s) did you attend?
Which college did you attend?
How old were you when you left education?(If haven't left education, leave it blank)
Enter the age when you left education
I have GCSE English, Grade 9-4/A* - C
Yes
No
Unsure
I have GCSE Maths, Grade 9-4/A* - C
Yes
No
Unsure
Please select the highest qualification you have achieved so far
Please select...
None
Unknown
Entry Level (1, 2, 3)
Level 1
Level 2
Level 3
Level 4+
Please tick all statements that apply to you
None
Received free school meals
Parents/Guardians claimed benefits
Currently pregnant
Currently in council/supported housing
Have lived in care at some point
Less than 5 GCSEs, 9-4/A*-C
Currently have caring responsibilities
Currently homeless NFA or sofa surfing
Court case pending in next 6 weeks
Criminal Record
Family involved in crime
[Other Stress Factor]
Other Stress Factor Details:
Do you have a Criminal record or have been to prison
Yes
No
Criminal record details
What are the big challenges going on in your life at present (e.g. housing, bad health, violence etc.)?
What other organisations/services are supporting you?
What is the name of your keyworker?
Do you have any children?
No
Yes - lone & teenage parent
Yes - lone parent
Yes - neither lone or teenage parent
Yes - teenage parent
Yes
If so, please give details (e.g., are you responsible for their childcare, when, etc.?)
Are you a single parent?
Yes
No
Are/were you a parent in your teenage years?
Yes
No
Do you have a physical disability?
Yes
No
If yes to the Physical Disability, please give details
Do you have any mental health concerns?
Yes
No
If yes to the Mental Health concerns, please give details
Do you have any Learning Disability?
Yes
No
If yes to the Learning Disability, please give details
Use the space below to write a few sentences about how you think the Spear Programme will help you get a job:
Are you interested in pursuing...
Please select...
Apprenticeship
Education
Work
Choose two preferences from the following that you would be interested in pursuing:
Childcare
Construction
Hospitality
IT
Retail
Other
If 'Other' what industry are you interested in?
If you are interested in education are you interested in:
College
Part-Time Study
University
COVID information
Since 16th August, people who are not fully vaccinated will still need to self-isolate after coming into contact with someone who has tested positive for Covid-19. Please let us know which of the following is true for you, so that we are aware of the likelihood of you having to isolate during the Spear programme. This information will not effect your place on the programme
Declaration
• I understand that Spear Foundation is a 6-week commitment and I am able to attend every day.
. I have read and understood the Spear expectations and by signing this form I agree to follow them whilst I am on the Programme.
• I understand that, should I share information suggesting that myself/others are at risk of harm, my coach will discuss this with me before gaining advice from the team/other relevant professionals
• I declare that the above information is true to the best of my knowledge and I consent to Resurgo Trust keeping, using and producing information relating to my registration.* Any information that is reported will be anonymised and not linked to your name. For more information please see our privacy policy (
http://www.resurgo.org.uk/resurgo/about-resurgo/privacy/
)
• I understand that if I am in receipt of any benefits, my entitlement to those benefits will not be affected whether or not I choose to give consent.
• I understand that any disclosures I make will be treated as confidential and kept within the Spear team, unless I am, or others are, at risk of harm. In this case, I will be informed that my disclosure may be shared.
• As part of finding you the best opportunities we may share your details with potential employers and education providers. A coach will always notify you if this is going to happen
* All data will be used in line with the requirements of the GDPR 2017 and data will be stored securely and destroyed after retention period has passed
Terms and Conditions
I Agree to the above declaration
Do you consent to your image being shared by Resurgo on our website, social media, newsletters, and articles? (An example of ‘your image’ could include a screenshot of one of your Zoom sessions).
Yes
No
Are you under 18?
Yes
No
Please provide an email address for your Parent/Guardian so we can get consent for you participating in this programme
Contact Information