ENROLMENT 1234567891011 HiddenUntitled HiddenUntitled Name* First Last Date of birth* DD slash MM slash YYYY Job Title* Gender*MaleFemaleOtherNational Insurance Number* Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Phone*Email* Name of next of kin* Relationship of next of kin to you* Phone number of next of kin*Email address of next of kin* Are you undertaking any other qualification/course?* Yes No I agree to JTM accessing my Personal Learning Record(PLR)* Yes No I am legally eligible for employment in the UK and that the information that I have given is correct* Yes No Are you currently receiving support from any other service or agency?* Yes No Prefer not to answer If yes, are you happy for a member of JTM’s Safeguarding Team to contact you to discuss any support needs?* Yes No Are you currently in employment?* Yes No Name of Employer* Employer Contact Name* Employer Email* Employer Address* Street Address City County / State / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Employer Phone Number*TIme Employed* Length of Time Unemployed Number of EmployeesPlease enter a number greater than or equal to 1.Hours Worked Per Week Days Worked Per Week Benefit Status Indicator* JSA ESA Universal Credit Not Applicable Other Contact Preferences*Please select your contact preferences below Select All I agree to be contacted about courses or learning opportunities I agree to be contacted for survey and research I agree to be contacted by post I agree to be contacted by telephone I agree to be contacted by email Which verification document will you use as part of your enrolment?*You must use one of these forms of ID to enrol on this course, please select which ID you will use. Passport Birth Certificate Ethnicity*Please select one of the options below. Bangladeshi Indian Pakistani Asian/Other Mixed - White and Asian Arab Black African Black Caribbean Black - Other Chinese Mixed - White and Black African White/Other Mixed - White and Black Caribbean Mixed - Any other mixed background White - British White - Irish Gypsy/Irish Traveller Not Known/Not Provided Do you consider yourself to have a health problem or a social barrier to learning?* Yes No Please Specify Below Do you consider yourself to have a learning disability?* Yes No Please Specify Below If ‘Yes’ to a learning disability/difficulty have you been given a full diagnosis?* Yes No If possible, can you provide any evidence for the diagnosis?* Yes No Eligibility For Funding*Please tick which of the following best describe your eligibility: Not attending school Not attending FE college full-time Not in higher education Not a graduate(i.e. Have a degree) Not in custody as a prisoner Not in custody on remand I have resided in England for a minimum of 3 years I hold a work permit covering the learning period I am not an overseas national subject to employment or learning restrictions and/or to a limit on their stay (other than a refugee or an asylum seeker) Unemployed Household Situation*Please tick which of the following best describes your household situation: No member of the household in which I live (including myself) is employed The household that I live in includes only one adult (aged 18 or over) There are one or more dependent children (aged 0-17 years or 18-24, if full-time student or inactive) in the household None of these statements I confirm that I wish to with-hold this information Qualifications and prior education and training*Please tick any relevant boxes GCSE's (Grades A-C or O Levels) GCSE's (Grades D-F) CSE's (Grade 1) A Levels AS Levels Access Course Degree HNC/HND Edexcel/BTEC Diploma GNVQ Intermediate or Higher NVQ Level 2 NVQ Level 3 NVQ Level 4 Other (Please state) Functional Skills English (state level) Functional Skills Maths (state level) Functional Skills ICT (state level) GCSE English GCSE Maths A Level English A Level Maths Highest Known Qualification* Educational/Training History*Schools/Colleges/TrainingFrom*To* LEARNER MUST: take responsibility for their own learning ensure full, and timely, attendance at assessments and workshops to enable them to successfully complete and pass the course comply with the organisational policies, procedures and codes of practice of both the training organisation and their employer help to set and achieve targets to sustain the successful completion of portfolios, and all assessments related to the course keep to an agreed overall timetable for completion of the course comply with safeguarding legislation adhere to equality and diversity legislation work in a safe manner and follow health and safety procedures EMPLOYER MUST: provide relevant procedures and documentation as required by Employment Law (ie Contract of Employment etc) allow regular on-site assessment and reviews from the training team allow the employee (learner) to attend off-site training sessions, if required wherever possible, appoint a mentor to oversee, help and guide the trainee in the workplace and in the production of a portfolio support the employee through the learning process and all other requirements of the course provide access to the widest range of work relevant to the specific assessment comply with safeguarding legislation ensure that health and safety regulations are followed provide health and safety information, equipment and training demonstrate a commitment to Equal Opportunities Name of training organisation: JARVIS TRAINING MANAGEMENT LTD (JTM) JTM'S RESPONSIBILITIES ARE TO: guide you through the various stages of your course, up to and including your final certification advise on, and agree with the employer and learner, a suitable learning programme with an anticipated end date co-ordinate initial / diagnostic assessments and organise any subsequent additional support that might be identified / highlighted provide quality work-based learning within the guidelines set by the awarding body of the qualification provide a personal assessor for all the elements of the programme and learning support where required endeavour to minimise disruption to your working day co-ordinate on and off the job learning and assessment opportunities administer and monitor the scheme on behalf of the Education and Skills Funding Agency (ESFA) and, if relevant, the European Social Fund (ESF) be at your disposal for any problems or questions throughout your programme We, the undersigned, understand our roles and responsibilities within this learning agreement and will honour them when and wherever possible.Name* First Last Email* Employer Name(If applicable) Contracted Hours of Employment(If applicable) Learners Job Role(If applicable) How Did You Hear About Us?FacebookInstagramSearch Engine (Google/Bing)Referred By A FriendLeafletNone Of The AboveReferrer DetailsFull Name* Email* Consent* I confirm that by submitting this form I agree to all of the JTM policies and the above details are correct. If you wish to read our data and privacy policies, please click here.HiddenUntitled HiddenUntitled