Functional Skills Maths Level 1 and 2 - Online - January, May, and September Start Dates

Learner enrolment form

Please confirm that you are enrolling on a Maths or English Functional Skills qualification, and you have not already achieved a GCSE grade 9-4/ A*-C in that subject Yes No

Learner's title Mr Mrs Miss Ms Other

Learner's first name

Learner's surname

Learner's date of birth DD/MM/YYYY (participants must be 19+)

Learner's National Insurance Number

Legal sex Female Male

How would you describe your gender? (optional)

Learner's ethnicity English / Welsh / Scottish/ Northern Irish / British Irish Gypsy or Irish Traveller Any other white background White and Black Caribbean White and Black African White and Asian Any other mixed / multiple ethnic background Indian Pakistani Bangladeshi Chinese Any other Asian background African Caribbean Any other Black / African / Caribbean background Arab Any other ethnic group Prefer not to say

Home address

Home post code

Learner's Contact Number (Home and mobile)

Learner's email address

Hampshire Achieves are committed to creating an inclusive learning environment. Do you have any mobility, accessibility, or learning support requirements Prefer not to say Yes No

If YES, please provide details below

Please note that you can make a request for additional support to your tutor or another member of staff at any time during your course

Do you have right to live in the UK and is the address given above your permanent address? Yes No

If NO, please explain your residence permit or visa status

Are you an Asylum Seeker? Yes No

If YES, how long have you lived in the UK?

Have you been granted leave to remain in the UK under any of the following schemes N/A Afghanistan scheme Ukraine scheme

What is your current paid work status? Please select an option Employed for less than 10 hours per week Employed for 11-20 hours per week Employed for 21-30 hours per week Employed for 31 hours or more per week I am looking to get back into employment and have been for less than 6 months I am looking to get back into employment and have been for 6 – 11 months I am looking to get back into employment and have been for 12-23 months I am looking to get back into employment and have been for 24 - 35 months I am looking to get back into employment and have been for 36 months or more I am not looking to get back into employment/retired and have been unemployed for less than 6 months I am not looking to get back into employment/retired and have been unemployed for 6 – 11 months I am not looking to get back into employment/retired and have been unemployed for 12-23 months I am not looking to get back into employment/retired and have been unemployed for 24 - 35 months I am not looking to get back into employment/retired and have been unemployed for 36 months or more

If you are currently employed, please select the appropriate length of time you have been employed 12 months or more 7 – 11 months 4 – 6 months 3 months or less N/A

Are you claiming any of the following types of benefits? None Job Seekers Allowance (JSA) Employment and Support Allowance (ESA) Universal Credit Other State Benefit

Please indicate the level of your highest current qualification by ticking the appropriate box None - No formal qualifications Entry Level - Certificate in Adult Literacy - Entry level 1-3 or Certificate in Adult Numeracy - Entry level 1-3 Level 1 - GCSE / O Level (5 or more at grades D-G or fewer than 5 at grades A*-C), NVQ level 1; GNVQ Foundation or BTEC first certificate; CSE below grade 1 Level 2 - Vocational and technical qualifications, Functional Skills or ESOL Qualifications at Level 2 Full Level 2 - GCSE / O Level (5 or more at grades A*-C, 9-4); CSE (5 or more at grade 1) or 2/3 AS levels; 1 A level; NVQ level 2; GNVQ Intermediate Level 3 - Vocational and Technical Qualifications at Level 3 Full Level 3 - 2 or more A levels; 4 or more AS levels or NVQ level 3; GNVQ advanced Level 4 - NVQ level 4; HNC Level 5 - NVQ level 5; HND; Foundation degree Level 6 - Degree BSc, BA; NVQ level 6 Level 7 or 8 - Higher degree MSc, Meng, MA; PGCE; NVQ level 7, Doctorates, PhD, DPhil Other - level not known

If Other level not known, please specify

Have you ever been a Looked After Child (In Care) / Are You a Care Leaver? No Yes Prefer not to say

Join our mailing list No Yes