Employ My Ability Referral Form

Learner details

Name of learner*
Address of learner*
Telephone no.*
date of birth (DD/MM/YYYY):*

Courses

Please note that all learners will be required to complete the induction skills package and encouraged to have taster sessions in a number of vocational areas before focusing on one vocational area.

Activities you would be interested in

Horticultural : working in the gardens / nursery

Yes
No

: specific wants
Catering : working the cafe, food preparation

Yes
No

: specific wants
Support : to get paid employment

Yes
No

: types of jobs
Support : to get voluntary jobs

Yes
No

: types of jobs
Administration : office work

Yes
No

: specific wants
Literacy and Numeracy

Yes
No

: specific wants
Other : please specify

Days / sessions you would like to attend *

Please note that a minimum of three days a week is needed to complete courses and qualifications.

MONDAY

AM
PM

TUESDAY

AM
PM

WEDNESDAY

AM
PM

THURSDAY

AM
PM

FRIDAY

AM
PM

Referrer details

Name of referrer*
Phone no. - referrer*
Email - referrer*
Relationship to learner*
Social worker of applicant
Ansbury advisor of applicant
Other professionals involved

Alternatively you can download and print the pdf of this form, fill it in by hand and return to Employ My Ability, The Walled Gardens, Moreton, Dorchester, Dorset DT2 8RH

If you have any queries about this form please contact jacqui@employmyability.org.uk or Tel: 01929 405 685

What happens next?

We will contact you within 24 hours of receiving a referral and arrange a Learner Assessment.