Move Well, Live Well - Fareham Library - Wednesday 4th, 11th, 18th, 25th November, 2nd and 9th December 2026 - 10.00am

Learner enrolment form

Learner's title Mr Mrs Miss Ms Other

Learner's first name

Learner's surname

Legal sex Female Male

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

Home address

Home post code

Learner's Contact Number (Home and mobile)

Learner's email address

Learner's NI number

Emergency contact name

Emergency contact number

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?

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

Do you have any additional needs? - mobility or learning support (if yes, please state in the comments box at checkout) No Yes

If YES, please provide details below

Would you like to receive information about the support available? No Yes

Would you like to be contacted by a member of staff to discuss your requirements? No Yes

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

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

Are you currently in paid employment? Yes No

If Yes 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 Self-employed for less than 10 hours per week Self-employed for 11-20 hours per week Self-employed for 21-30 hours per week Self-employed for 31 hours or more per week N/A

Also if Yes, How long have you been in your job (in years and months)

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

Eligibility Please select, learners must meet one of the following categories You are enrolling for a Maths or English Functional Skills qualification, and you have not already achieved a GCSE grade 9-4 / A*-C in that subject Do not have a Full Level 2 qualification (5 GCSEs grade 9-4/ A*-C or level 2 vocational qualification) Receive Income Support / Universal Credit Earn less than £26,800 annual gross salary At risk of / have mental health needs Currently unemployed and seeking work Have refugee status Have a learning difficulty of disability

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

If No I am retired and have been for less than 6 months I am retired and have been for 6-11 months I am retired and have been for 12-23 months I am retired and have been for 24-35 months I am retired and have been for 36 months or more 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 and have been unemployed for less than 6 months I am not looking to get back into employment and have been unemployed for 6-11 months I am not looking to get back into employment and have been unemployed for 12-23 months I am not looking to get back into employment and have been unemployed for 24-35 months I am not looking to get back into employment and have been unemployed for 36 months or more 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 tick one of the boxes below to indicate which best describes your reasons for wishing to enrol on this course. If more than one applies, please tick just your main reason To improve my confidence and willingness to engage in learning To acquire skills preparing me for training or further learning To acquire skills preparing me for employment or self-employment To improve my essential skills including English, ESOL, Maths and Digital To be better equipped as a parent/carer to support and encourage my childrens learning To improve or maintain my health and/or social well-being To help develop stronger communities, with more self-sufficient, connected and pro-active citizens

How did you hear about this course? Brochure online Leaflet Email Social media Local paper Word of mouth Library website From tutor WI magazine External poster or banner Prefer not to say

Join our mailing list No Yes