Legacy Empowered Employability Registration Form

'Empowered' is Legacy Youth Zone's 'Employability ready' employability programme for young people based at Legacy Youth Zone, Croydon. Our 6 week, part time, programme provides young people with the skills and opportunities they need to support them on their journey into employment or further education and to identify positive pathways.

Name*

Please provide your full name

Preferred name*

Let us know what you prefer to be known as

Self referral*

Select

Name of referer

If you are referring a young person, please let us know your name.

Referer contact details

If you are referring a young person, please provide us with your contact details so we can discuss the referral with you.

Relationship with young person

If you are referring a young person, please let us know in what capacity you know the individual.

Date of Birth*

Please provide you date of birth.

Age*

Let us know your age.

Address*

Please provide your full address details

London Borough

Please let us know what borough you live in.

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Email address*

We want to be able to contact you and share information with you. Please provide your email address for us to do so.

Contact number*

Gender*

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Ethnicity*

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Looked after child*

A looked after child is someone who is in the care of their local authority through a young persons care home or foster care. A care leaver is someone aged 16-25 who has been 'looked after' at some point since they were 14 years old, and were in care on or after their 16th birthday. This information is required for our funders and does not make in impact on the application process.

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Additional needs*

Do you have any additional needs that we need to be aware of so we can ensure you are fully supported through the programme?

Please provide more information about your additional needs

Currently learning*

Are you currently in any further education including college, sixth form, training or work.

Select or enter value

College, training or work additional information

Please provide more information about your current status of studying or working

Do you work with anyone else?

Are you, or have you, worked with any other services and organisations? For example, family support worker, probation services, gangs team, school or college, social worker, youth engagement team etc. Please provide information below if so.

Criminal convictions*

Do you have any criminal convictions?

Select or enter value

More information about criminal convictions

Please provide us some more information about and convictions you may have. This helps us support you with access to services and information.

Why do you want to be part of the 'Break the Cycle' programme?

Are you ready?*

Are you ready to commit to the 'Break the Cycle' programme?

Select

Do you have a current CV. If so, upload it here.

Drag and drop files here or

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