NKC REGISTRATION FORM
Mr
Ms
Miss
Mrs
Surname:
First Name:
Preferred Name if applicable (what should we call you?)
Email:
Mobile No:
Your Ethnic Origin
Asian - Indian
Asian - Bangladeshi
Asian - Pakistani
Asian - Other
Black - British
Black - Caribbean
Black - African
Black - Other
Chinese
Ethiopian
Eritrean
Filipino
Irish
Mixed - White & Asian
Mixed - White & Black African
Mixed - White & Black Caribb
Mixed - Other
Moroccan
Portuguese
Somali
Spanish
Sudanese
White - British
White - Other
Prefer not to say
Please let us know if you have a Disability
Yes
No
If yes please specify
Asthma
Emotional/behav. difficult.
ME
Multiple Disabilities
Temp Disability After Illness
Visual Impairment
Severe Learning Difficulties
Disability Affecting Mobility
Epilepsy
Mental Ill Health
Profound Complex Disab.
Unseen Disabilities
Hearing Impairment
Asperger's
Dyscalculia
Dyslexia
Dyspraxia
Moderate Learn. Difficult.
Multiple Learn. Difficult.
Other -
Do Not Wish To Declare
Are you disavantaged
Yes
No
if yes please specifyl
Ex Offender
Refugee/Migrant
Carer
Live in Rural Area
Lone Parent
Homeless
Recovering from Drug/Alcohol Addiction
Other -
Do Not Wish To Declare
Progress: 0%
Page 1 of 3
Web form built with
Simfatic Forms dynamic web form builder
.