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Integration Gates Registration

First Name
Family Name
Address
Home Telephone
Mobile
Date of Birth
National Insurance No.
Nationality

Ethnic Origin please select ONE that applies to you
Asian/Asian British Bangladeshi
Asian/Asian British Indian
Asian/Asian British Other
Black/Black British African
Black/Black British Caribbean
Black/Black British Other
Chinese
White
Other
Equal Opportunities
Please select any of the following that apply to you
English 2nd Language
Refugee
Asylum Seeker
50 plus years
EEC National
Do you consider yourself to be disabled
 Yes No
Are you physically disabled
 Yes No
Are you blind or partially sighted
 Yes No
Are you deaf or hard of hearing
 Yes No
Do you have a mental health problem or issue
 Yes No
Do you have a learning disability
 Yes No
Do you have a speech or language difficulty
 Yes No
Health Problems
Please give details of any health problems		  
 
Declaration

I understand this service is voluntary and give my consent for my personal details to be used to confirm my identity and be released to funders, partners and referral organisations.  Personal information is used for the purpose of management information and external audit requirements.

You may be contacted in the future with regard to monitoring, evaluation and offering further assistance.  Details provided on this form are confidential and will not be used for any purpose other than already stated.  This information may be held and used in the service's internal computer system.

I understand that I can withdraw this consent at any time by contacting a member of staff.

Agree

Disagree
   

 

 

INTEGRATION GATES CIC
 Newcastle Enterprise Centres Lynnwood i8,Unit 8, Lynnwood Terrace Newcastle upon Tyne, NE4 6UL United Kingdom
Telephone 0191 272 5627  Fax 0191 226 0876