861 Holderness Road, Hull. HU8 9EZ

Tel: 01482 702571

E-mail:

Web:

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Certificate in Therapeutic Work with Children and Young People

2017 Entry

Equal Opportunities Monitoring Form for Course Applicants

The Ellesmere Centre for Psychotherapy and Training believes in equal opportunities.The Equality Act 2010 states that all organisations are required to demonstrate that their application processes are fair and that they are not discriminating against or disadvantaging anyone because of their age, disability, gender reassignment status, marriage or civil partnership status, pregnancy or maternity, race, religion or belief, sex or sexual orientation.

The information collected is only used for monitoring purposes in an anonymised format to assist the Ellesmere Centre analyse the profile and make up of individuals who apply for courses. In this way, we can check that they are complying with the Equality Act 2010.

Please tick the appropriate boxes:

1. Gender

Male

Female

If you are undergoing the process of gender reassignment, please tick the box that applies to your future gender.

2. What age group do you belong to?

20-24

25–29

30-34

35-39

40-44

45-49

50-54

55 and over

Prefer not to say

3. What is your sexual orientation?

 Bi-sexual

 Gay Man

 Gay Woman / Lesbian

Heterosexual / Straight

 Prefer not say

 Other sexual orientation (Please specify): ______

4. What is your marital status?

 Civil partnership

Divorced

 Legally separated

Married

Single

Widowed

Prefer not to say

5. Do you have dependants?

 No

 Yes

 Prefer not to say

6. Do you have a religion or similar belief?

 No

 Yes

 Prefer not say

If you have answered YES above, please give details:

Atheism

 Buddhism

 Christian

 Hinduism

 Islam

 Jainism

 Jewish

 Judaism

 Muslim

 Sikhism

 Other religion or similar belief: ______

7. Do you consider that you have a disability?

 Yes

 No

 Prefer not to say

8. If you have a disability, please state the type of impairment which applies to you.

People may experience more than one type of impairment, in which case you may indicate more than one. If none of the categories apply, please mark ‘other’.

Learning Disability/Difficulty

Long-standing illness

Mental health condition

Physical impairment

Sensory impairment

Other: please specify: ______

9. How would you describe your ethnic origin?

Asian or Asian British

Bangladeshi

Indian

Pakistani

Any other Asian background

Black or Black British

African

Caribbean

Any other Black background

Mixed

White & Asian

White & Black African

White & Black Caribbean

Any other mixed background

White

British

Irish

Any other Whitebackground

Other Ethnic Group

Chinese

Any other ethnic group

Prefer not to say

Thank you for your help.

John Bradley Registered Member MBACP (Snr. Accred) Course Facilitator and

Kathie Hostick CTA TSTA Centre Director

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