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ADULT COMMUNITY LEARNING SERVICE

ENROLMENT FORM

Learner ID (Office use only)

Course Title:

Course Code:

Day:

Time:

HoursMinutes

Actual Start Date:

Actual Start Date: Month Day Year

Title:

Other: If other title please state:

Last Name:

First Name(s)

Address:

Postcode:

Telephone Number (Home)

Telephone Number (Work)

E-Mail Address:

Date of Birth:

Date of Birth: Month Day Year

Nationality:

Gender:

Have you been permanently resident in the UK for the last 3 years?

If you answered NO to the last question, please state the country where you were resident:

Do you consider yourself to have a disability?

If you answered YES to the above question please indicate your disability/disabilities

Deaf/Partial Hearing
Mobility
Blind/Partial Sight
Mild Learning Difficulty
Severe Learning Difficulty
Dyslexia
Other

My ethnic origin is:

Black Caribbean

Black African

Any other Black background

Indian

Pakistani

Bangladeshi

Any other Asian background

White British

White Irish

Any other White background

White & Black Caribbean

White & Black African

White & Asian

Any other mixed background

Chinese

Any other ethnic group

Not given

If other, please specify:

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North East Lincolnshire Council, Municipal Offices, Town Hall Square, Grimsby, DN31 1HU, (01472) 313131

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