Integrated Youth & Community Services

YOF Panel Application Form[YOF04 Form]

Please email your completed forms to Boris Rupnik () by 15thMay 2015. Alternatively you can post them to Boris Rupnik, IYCS, 5thFloor, Mulberry Place, 5 Clove Crescent, London, E14 2BG

Young Person Details – please give the name you use(d) at school

Family Name
First Name(s)
Nickname/Preferred name
Date of Birth
Are you currently in Education, Employment or Training? / YES / NO
Last School/College Attended
Address
Postcode
Telephone (Mobile) / Telephone (Home)
Email
Why do you want to be a part of the Project?
What skills or the experiences do you think you can contribute to the Project?

Equality Monitoring

We want to make sure that all our services are delivered fairly and include everyone’s needs. The information provided will help us to improve our services to you and others in Tower Hamlets. With up-to-date and accurate information we are able to, better understand our service users / residents to meet their specific needs, identify any possible discrimination or barriers to accessing our services (or information about our services) for different groups of people and anticipate and avoid potential difficulties for some people and work to remove them.

Tower Hamlets Council monitors the delivery of services to ensure that they are representative of all communities and that all service users are treated fairly. The information you provide on this questionnaire will remain strictly confidential, in accordance with the Data Protection Act 1998. Information will only be used by Tower Hamlets Council or other arms length organisations in the Tower Hamlets Partnership, such as Tower Hamlets Homes.

You do not have to answer these questions. If you choose not to answer these questions, it will not make any difference to the service you receive. By answering these questions you will help us to ensure that our services are fair and accessible to all.

Gender

Male
Female
Trans
Intersex
Prefer not to say

Do you live and work full time in the gender role opposite to that assigned at birth?

Yes
No
Prefer not to say

Religion and belief (please tick appropriate box)

No Religion
Agnostic
Muslim
Christian
Jewish
Buddhist
Sikh
Hindu
Humanist
Other Religion (please specify)
Prefer not to say

Ethnicity

Please note that this question does not refer to your nationality/ country of origin. These categories are based on the 2011 Census categories but include categories to reflect the communities of Tower Hamlets.)

I would describe my ethnic origin as:-

White: British
White: Irish
White: Traveller of Irish Heritage
White: Gypsy/Roma
White: Other
Black or Black British: African
Black or Black British: Somali
Black or Black British: Caribbean
Black/Black British/ Other Black Background
Asian or Asian British: Bangladeshi
Asian or Asian British: Pakistani
Asian or Asian British: Indian
Asian/Asian British/Other Asian Background
Mixed/Dual Heritage: White & Black Caribbean
Mixed/Dual Heritage: White & Black African
Mixed/Dual Heritage: White & Asian
Mixed/Dual Heritage: Any Other Mixed Background
Other Ethnic Groups: Vietnamese
Other Ethnic Groups: Chinese
Other Ethnic Groups/ Any Other Group
Prefer not to say

Disability

Do you consider yourself to have a disability according to the terms given in theEquality Act 2010?

(Under The Equality Act 2010, a person is disabled if they have a physical or mentalimpairment which has a substantial and long-term adverse effect on their ability to carry out normal day-to-day activities, which would include things like using a telephone, reading a book or using public transport.)

Yes
No
Prefer not to say

Please state the type of impairment that 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’ and specify the type of impairment.)

Sensory impairment, (such as being blind / having a visual impairment or being deaf / having a hearing impairment)
Physical impairment, (such as using a wheelchair to get around and / or difficulty using your arms)
Learning disability, (such as Downs syndrome or dyslexia) or cognitive impairment (such as autism or head-injury)
Mental health condition, (such as depression or schizophrenia)
Long-standing illness or health condition (such as cancer, HIV, diabetes, chronic heart disease, or epilepsy)
Other (please specify)
Prefer not to say

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