Work Less, Make More Registration Form
Mr
Ms
Miss
Mrs
First Name:
Surname:
Date of Birth:
dd/mm/yyyy
Male
Female
Address 1
Address 2
Address 3
Post Code:
Borough:
Royal Borough of Kensington and Chelsea
City of Westminster
Barking and Dagenham
Barnet
Bexley
Brent
Bromley
Camden
Croydon
Ealing
Enfield
Hackney
Hammersmith and Fulham
Haringey
Harrow
Havering
Hillingdon
Hounslow
Islington
Lambeth
Lewisham
Merton
Newham
Redbridge
Richmond upon Thames
Royal Borough of Greenwich
Royal Borough of Kingston upon Thames
Southwark
Sutton
Tower Hamlets
Waltham Forest
Wandsworth
Other
Less than a year
A year to 5 years
More than 5 years
More than 10 years
How long have you lived in the borough
Qualifications
No qualifications
Level 2 (GCSEs)
Level 3 (A level)
Level 4 (Degree)
Level 5 (Post Graduate)
Other qualification
Mobile No:
Email:
Are You
At College/School
Working part-time
A carer Registered
A carer Unregistered
Unemployed - registered
Unemployed - not registered
Working full-time
Self Employed
Stay at home parent
for how long?
6 to 21 mnths
13 to 18 mnths
18 to 23 mnths
over 24 mnths
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
Housing benefit
Family tax credit
Income benefit
The following questions will enable us to check if you are eligible for any grants that may be available:
Are you claiming benefits such as
Yes
No
Do you live in rented accommodation?
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