Referral Form - Inspiring Leadership Foundation

This form helps us learn more about you so that we can support you in the best way possible. All information is held confidentially by the Inspiring Leadership Foundation and only shared with individuals who are directly responsible for your development. To ask any questions, please contact us at [email protected].

Please note that all questions with an asterix (*) must be completed.

1. Are you completing this form for yourself or on behalf of someone else? *

a) For myself

b) On behalf of someone else

c) I am submitting a group referral

To be completed by the applicant:

2. First Name *

3. Surname *

4. Date of Birth *

5. Email address *

6. Phone Number *

7b. Ethnicity 7b. Ethnicity

Education and Employment

10. Tick the box below that best describes your income status *

Below Minimum Wage

Low Income

Income Support

OtherOther

Support Needs

11a. Which of these do you feel like you lack? *

Confidence/ positive wellbeing

Employability skills

Autonomy (ability to make your own decisions)

Healthy relationships and/or feeling like part of a community

Financial Independence

Income and/or employment

11b. Why do you need support? (Please check all that apply) *

To improve your confidence and/or wellbeing

To improve your employability skills

To gain autonomy so that you can better make your own decisions and determine the course of your life

To experience healthy relationships and feel part of a community

To achieve income and/or employment

To achieve financial independence

13.To assist with mentor matching, can you please specify the field you would like to pursue a career in the future?

14. What technology do you have access to? *

Laptop, ipad, tablet or Desktop computer

Smart phone

No access to technology

OtherOther

Select as many as suitable of:

15. Have you got access to internet and/or mobile data? *

Yes

No

Additional Information

16. Are you a single parent? *

Yes

No

16b. How many dependents do you have?

17. Are you a refugee or asylum seeker? *

Yes

No

18. Tell us about yourself

19. Have you received support from the Inspiring Leadership Foundation before? *

No

Yes (Please provide details)Yes (Please provide details)

How did you here about us?

Declaration

I declare that the information provided in this form is true and complete to the best of my knowledge.

Signature of applicant *

Clear

Yes, I authorise the Inspiring Leadership Foundation to communicate directly.

To be completed by referring partner/ by someone on behalf of the beneficiary:

20. Your First Name *

21. Your Surname *

22. Your Contact Number *

23. Email Address *

24. Relationship to the candidate

Your relationship to the beneficiary/ the person you are completing this form on behalf of:

25. Candidates First Name *

26. Candidates Surname *

27. Candidates Mobile Number *

28. Candidates Home Number

29. Candidates Email Address

30. Candidates Date of Birth *

31. Candidates Education *

what are they studying? What are their future education plans?

32. Candidates Qualifications *

What qualifications has the beneficiary earned?

33. Candidates Work Experience *

What work experience does the beneficiary have?*

34. Candidates Strength and Interests *

What are the candidate’s strengths and their interests and hobbies?

35. Candidates Development *

What are the areas the beneficiary like to develop and learn about?

36. Candidates work experience placements *

What type of work experience placements would the beneficiary like us to find for them?

37. Do they need to attend with a parent / carer? *

Yes

No

39. What computer skills do they have? *

They have used MS Office before and feel comfortable using it

They have used MS office before but do not feel comfortable using it

They do not have experience using MS Office

They have used other computer software (please specify) They have used other computer software (please specify)

Select as many as suitable of:

40. Which days/times of the week are they free to attend the masterclasses? *

What type of work experience placements would the beneficiary like us to find for them?

41. Do they need to attend with a parent / carer? *

Yes

No

42. Candidates Personality and Social skills *

Can you tell us more about the candidate’s personality and social skills?

43. Candidates Background *

Can you provide some background information to help us fully understand the candidate's needs (family situation, current living arrangements, difficulties, etc.)

44. Anything Else? *

What else should the team be aware of?

IMPORTANT COMMUNICATION AUTHORISATION

To ensure that we follow the right protocols, please confirm if the Inspiring Leadership Trust (ILT) can communicate with the applicant directly regarding their programme.

Authorisation *

Yes, I authorise the ILF to communicate directly

Yes, the ILF can communicate with the applicant directly, copy the following people on all correspondence.

No, the ILF must use this alternative contact and not communicate directly.

Signature of referring partner *

Clear

To be completed by referring partner/ by someone on behalf of the beneficiaries:

20. Your First Name *

21. Your Surname *

22. Your Contact Number *

23. Email Address *

24. Relationship to the candidates

Your relationship to the beneficiary/ the person you are completing this form on behalf of:

IMPORTANT COMMUNICATION AUTHORISATION

To ensure that we follow the right protocols, please confirm if the Inspiring Leadership Trust (ILT) can communicate with the applicants directly regarding their programme.

Authorisation *

Yes, I authorise the ILT to communicate directly

Yes, the ILT can communicate with the applicant directly, copy the following people on all correspondence.

No, the ILT must use this alternative contact and not communicate directly.

Signature of referring partner *

Clear

Candidate names and details

Candidates First Name

Candidates Last Name

Candidates Phone Number

Candidates Email Address

Add Remove

Privacy Policy

I have read and agree with the ILF Privacy Policies and Terms and Conditions.

The privacy policy page includes our global ethics documentation and our GDPR Policy.

Application / Referral Form

If you or a a girl or woman that you know would benefit from our support, please fill in this form.

To be completed by the applicant:

Education and Employment

Support Needs

Additional Information

Declaration

To be completed by referring partner/ by someone on behalf of the beneficiary:

IMPORTANT COMMUNICATION AUTHORISATION

To be completed by referring partner/ by someone on behalf of the beneficiaries:

IMPORTANT COMMUNICATION AUTHORISATION

Candidate names and details

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