Initial Engagement

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Initial Engagement

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The information gathered on this form, is so we can ensure we are getting to know you, your circumstances and can offer you the best support and advice possible. It is stored securely on our system. This information must be completed before any activities are undertaken as part of the project. These details will be stored securely and retained for 6 years from first engagement with our service in compliance with applicable data protection law. This information will be used to evaluate the project and the outcomes. You may be contacted to discuss your involvement in the project. For the purposes of data protection act 2018, Newground Together is the data controller in respect of information processed which relates to your participation in the project.

Mentor
Venue*
Date*
Unique Participant ID No.	0

Contact Info

Title*

First Name*

Forename is required

Middle Name

Text 3 is required

Surname (s)*

Surname is required

Like to be known as

Greeting is required

I identify my gender as*

Male

Female

Transgender

Other

Non-Binary

Date of Birth*

Date Of Birth is invalid, use the following format dd-mmm-yyyy

Participant Address*

Postcode:

Building Name:

Secondary Name:

Street:

District:

Town:

County:

Household Status*

Owns with either a mortgage, loan or shared ownership	Private rent tenant
Hostel/ Temp Acc.	No Fixed Abode
Social Housing	Owned outright (no mortgage)
Not Known

Do you have an email address

Yes No

Email Address*

Email is required

Mobile Phone*

Mobile is required

Mobile Phone must be 11 digits

Home Telephone

Telephone is required

Home Telephone must be 11 digits

NI Number*

National Insurance is required

Emergency Contact Details

First Name*	Emergency Firstname is required
Surnames*	Emergency Surname is required
Mobile Number*	Emergency MobileNumber is required
Other Number	Emergency OtherNumber is required
Relationship to you*	Emergency Relationship is required

Equality & Diversity Information

Do you describe yourself as having a Disability? *

Which Ethnicity do you describe yourself as?*

asian/asian british - bangladeshi	asian/asian british - chinese
asian/asian british - indian	asian/asian british - pakistani
Asian, Asian British or Asian Welsh	asian/asian british - other
black/african/caribbean/black british - african	black/african/caribbean/black british - caribbean
black/african/caribbean/black british - other	Black, Black British, Black Welsh, Caribbean or African
mixed/multiple - white and asian	mixed/multiple - white and black african
mixed/multiple - white and black caribbean	mixed/multiple - other
Mixed or Multiple ethnic groups	white - english/welsh/scottish/northern irish/british
white - irish	white - roma, gypsy or irish traveller
Gypsy, Irish Traveller or Roma	white - other
other ethnic group - arab	White
other ethnic group - other	Other ethnic group