Family Hub Enrolment Form

Privacy notice

Your information is collected on this form for the following reasons:

• The training you are applying for is funded through a grant from the Education and Skills Funding Agency. Your information will be shared with them so the council can claim the funding.

• Your information will be shared with the course provider so they can deliver your course.
For full details of the council’s privacy notice please visit our website County Council Privacy Notice.
Details of the Education and Skills Funding Agency Privacy Notice is included at the end of the form.
Your provider will check you are eligible for the course using the four questions below. Please tick yes or no. If you tick no to any of the questions, your tutor may need more details to confirm your enrolment.
If you tick no to any of the below, your tutor may need more details to confirm your enrolment.
You are a citizen of the UK/EEA
YesNo
You have lived in the UK/EEA for the last 3 years
YesNo
You are a Staffordshire resident (you live in: Cannock, East Staffs, Lichfield, Newcastle, South Staffs, Stafford, Staffs Moorlands OR Tamworth)
YesNo
Were you 19 or over on 31st Aug 2024
YesNo

Section 1 - Course details
Provider
Course code
Course title
Course start date:
Course end date

Purpose of Community Learning
Please tick one option below to say why you are doing this course?

Section 2 - Your details
Title
First name
Last name
Date of birth
Nationality
Sex
MaleFemale
If you wish to give further details (for example, your preferred pronouns) please do so:
National insurance number

Please fill this with no spaces. For help finding your national insurance number, please go to gov.uk website
Email
Mobile phone
Landline phone
Address
Address Line 1
Town
Postcode
Have you lived at this address for the past 3 years?
YesNo

Section 2a - Personal details (previous address)
Please state your previous address
Address line 1
Town
Postcode

Section 2b - Emergency contact details

Your welfare is important to us and we request this information in the event of an emergency whilst you are on your course. Please ensure you let the individual know that you have named them as your emergency contact.
Emergency contact name

First name

Last name
Emergency phone number
Relationship to you

Section 2c - Monitoring
Please choose the category closest to your ethnic background. This is not your nationality
English / Welsh / Scottish / Northern Irish / BritishIrishGypsy or Irish TravellerAny other White backgroundWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other mixed / multiple ethnic backgroundIndianPakistaniBangladeshiChineseAny other Asian backgroundAfricanCaribbeanAny other Black / African / Caribbean backgroundArabAny other ethnic groupPrefer not to say
Do you consider yourself to have a disability, learning difficulty or health problem?
YesNo
Please tick all that apply
Asperger’s syndromeAutism spectrum disorderDisability affecting mobilityDyscalculiaDyslexiaHearing impairmentMental health difficultyModerate learning difficultyProfound complex disabilitiesSevere learning difficultySocial and emotional difficultiesSpeech, language and communication needsTemporary disability after illness (for example, post viral) or accidentVision impairmentOther physical disabilityOther specific learning difficulty (e.g. dyspraxia)Other medical condition (e.g. epilepsy, asthma, diabetes)Other learning difficultyOther disabilityPrefer not to say
If you have indicated more than one option, please state your primary disability or learning difficulty:

Section 3 - Existing qualifications
Do you have any existing qualifications? If yes, please select the highest level you have:

Section 4 - How did you hear about this course
Have you attended a course with the Community Learning Service or any other provider in the last 3 years?
YesNo
How did you hear about this course?
If other - please state

Section 5 - Employment status
I am:
Hours worked per week
Length of unemployment if unemployed and looking for work.
I do regular voluntary work
YesNo

We may want to contact you in the next 18 months for the following reasons. Please indicate if you are happy for us to do this and also how you would prefer us to make contact:
About similar courses and learning opportunities that you may be interested inTo ask about your experience of attending this course and if you found the learning usefulBy postBy phoneBy email
For full details of the council’s privacy notice please visit our website County Council Privacy Notice.
ILR Privacy notice

This privacy notice is issued by the Education and Skills Funding Agency (ESFA) on behalf of the Secretary of State for the Department of Education (DfE) to inform learners about the Individualised Learner Record (ILR) and how their personal information is used in the ILR. Your personal information is used by the DfE to exercise our functions under article 6(1)(e) of the UK GDPR and to meet our statutory responsibilities, including under the Apprenticeships, Skills, Children and Learning Act 2009. Our lawful basis for using your special category personal data is covered under Substantial Public Interest based in law (Article 9(2)(g)) of GDPR legislation. This processing is under Section 54 of the Further and Higher Education Act (1992). The ILR collects data about learners and learning undertaken. Publicly funded colleges, training organisations, local authorities, and employers (FE providers) must collect and return the data to the ESFA each year under the terms of a funding agreement, contract or grant agreement. It helps ensure that public money distributed through the ESFA is being spent in line with government targets. It is also used for education, training, employment, and well-being purposes, including research.
We retain your ILR learner data for 20 years for operational purposes (e.g. to fund your learning and to publish official statistics). Your personal data is then retained in our research databases until you are aged 80 years so that it can be used for long-term research purposes. For more information about the ILR and the data collected, please see the ILR specification
ILR data is shared with third parties where it complies with DfE data sharing procedures and where the law allows it. The DfE and the English European Social Fund (ESF) Managing Authority (or agents acting on their behalf) may contact learners to carry out research and evaluation to inform the effectiveness of training.
For more information about how your personal data is used and your individual rights, please see the DfE Personal Information Charter and the DfE Privacy Notice
If you would like to get in touch with us or request a copy of the personal information DfE holds about you, you can contact the DfE in the following ways:
• Using our online contact form
• By telephoning the DfE Helpline on 0370 000 2288
• Or in writing to: Data Protection Officer, Department for Education (B2.28), 7 & 8 Wellington Place, Wellington Street, Leeds, LS1 4AW
If you are unhappy with how we have used your personal data, you can complain to the Information Commissioner’s Office (ICO) at: Wycliffe House, Water Lane, Wilmslow, Cheshire, SK9 5AF. You can also call their helpline on 0303 123 1113 or visit the ico website
Date last updated: 31 Jan 2024
I consent to the use of my name, date of birth and other relevant data as set out above being shared with the relevant organisations. I understand that this will not be used for any other purpose without my consent, unless authorised to do so by law.
I accept

Learning agreement

By submitting this form, you are agreeing to the following statements:
• I have been given advice and information and discussed any support needs I have.
• The aim of the course is appropriate to my purpose for learning and existing skills.
• I understand the times and dates of sessions, any costs and materials I need to bring.

I agree to:
• arrive on time and participate in every session of the course
• tell the tutor if I can’t attend
• respect other people and not show any prejudice towards others
• agree some ground rules for the class with other learners and the tutor
• take care of any materials and equipment
• follow health and safety regulations
• talk to the tutor if I have any concerns about my learning or learning environment

I understand and agree that:
• I will inform the tutor if any circumstances detailed with in this form change during my programme.
• If I have declared false information, action may be taken to redeem any course fees and any associated costs from me.
• I will pay any fee for which I am liable as per the Council’s Fee Policy.
• If I withdraw, all fees will remain payable in full as per the Council’s Fee Policy.
• I have accurately described my existing qualification level, and employment status.
I confirm that the completed information submitted on this form is correct and this constitutes my Learning Agreement with Staffordshire County Council
I confirm
I confirm images and/or footage I submit as evidence of my learning for this course to be stored by Staffordshire County Council for up to 7 years.
I confirm
I confirm I am authorised to sign on behalf of the learner
I confirm
Name

First name

Last name

Computer and digital conditions of use

Staffordshire County Council online courses are available to learners who confirm that they understand and agree to the following Conditions of Use.

1. You are responsible at all times for the way that you use a computer/device and the internet.

2. If you do not follow by these conditions or you behave in a way which is not acceptable to other users, you will be asked either to restrain your behaviour or you will be stopped from accessing the course.

3. The following lists some of the actions which are not acceptable and may result in your access to the course being withdrawn, at the discretion of the tutor/Staffordshire County Council staff:
- Allowing someone else to access the course using your access permission.
- Any deliberate damage to the computer or network in line with the Computer Misuse Act 1990.
- Accessing or sharing any material that promotes radicalisation or extremism.
- Using the internet or other storage to access, copy or share any material that is unlawful or is likely to be considered offensive including any materials that are intimidating, discriminatory, racist, sexist, homophobic, defamatory materials, encourage violence or hatred, or nude/semi-nude images or video.
- Transmitting, copying, or downloading any material without the permission of the copyright holder.
- Behaving in a manner which is likely to be seen as harassment, cyber-bullying, grooming or phishing, or cause offence or embarrassment to other users.

4. The County Council accept no responsibility or liability for any matter, claim, action, inaction proceedings, demand, damage, loss, cost, charge or expense which any person may suffer or incur, either directly or indirectly through the use of this service.
I confirm that I have read and agree to the above Computer and digital conditions of use
I confirm

Data For Children

Because you are enrolling on a Family Hub course we need to collect additional data about your relevant children. The information you provide to Staffordshire County Council (Data Controller) will be processed in line with the Data Protection Act 2018. It will be used to provide and administer services, offer support to families and for evaluation purposes. We may share your data with partners who are working on behalf of Staffordshire County Council in order to provide these services or where we are required to by law. For our full privacy notice please see: information about your data

Data Protection Officer: Tracy Thorley infogov@staffordshire.gov.uk
I Acknowledge
Confirm

Child's First Name
Child's Last Name
Child's Date Of Birth
Sex
Ethnicity
Disability, if applicable - Please tick all that apply
Autism Spectrum disorderBehavioural Emotional and Social Difficulties (BESD)Physical DisabilityVisual ImpairmentHearing ImpairmentMulti Sensory ImpairmentSpecific Learning DisabilityModerate Learning DifficultySevere Learning DisabilityProfound and Multiple Learning DisabilityOther (please state)
If other please state
Do you wish to add any additional children?
YesNo

Child's First Name
Child's Last Name
Child's Date Of Birth
Sex
Ethnicity
Disability, if applicable - Please tick all that apply
Autism Spectrum disorderBehavioural Emotional and Social Difficulties (BESD)Physical DisabilityVisual ImpairmentHearing ImpairmentMulti Sensory ImpairmentSpecific Learning DisabilityModerate Learning DifficultySevere Learning DisabilitySevere Learning DisabilityOther (please state)
If other please state
Do you wish to add any additional children?
YesNo

Child's First Name
Child's Last Name
Child's Date Of Birth
Sex
Ethnicity
Disability, if applicable - Please tick all that apply
Autism Spectrum disorderBehavioural Emotional and Social Difficulties (BESD)Physical DisabilityVisual ImpairmentHearing ImpairmentMulti Sensory ImpairmentSpecific Learning DisabilityModerate Learning DifficultySevere Learning DisabilitySevere Learning DisabilityOther (please state)
If other please state
Do you wish to add any additional children?
YesNo

Child's First Name
Child's Last Name
Child's Date Of Birth
Sex
Ethnicity
Disability, if applicable - Please tick all that apply
Autism Spectrum disorderBehavioural Emotional and Social Difficulties (BESD)Physical DisabilityVisual ImpairmentHearing ImpairmentMulti Sensory ImpairmentSpecific Learning DisabilityModerate Learning DifficultySevere Learning DisabilitySevere Learning DisabilityOther (please state)
If other please state
Do you wish to add any additional children?
YesNo

Child's First Name
Child's Last Name
Child's Date Of Birth
Sex
Ethnicity
Disability, if applicable - Please tick all that apply
Autism Spectrum disorderBehavioural Emotional and Social Difficulties (BESD)Physical DisabilityVisual ImpairmentHearing ImpairmentMulti Sensory ImpairmentSpecific Learning DisabilityModerate Learning DifficultySevere Learning DisabilitySevere Learning DisabilityOther (please state)
If other please state
Do you wish to add any additional children?
YesNo

Child's First Name
Child's Last Name
Child's Date Of Birth
Sex
Ethnicity
Do you wish to add any additional children?
YesNo
Disability, if applicable - Please tick all that apply
Autism Spectrum disorderBehavioural Emotional and Social Difficulties (BESD)Physical DisabilityVisual ImpairmentHearing ImpairmentMulti Sensory ImpairmentSpecific Learning DisabilityModerate Learning DifficultySevere Learning DisabilitySevere Learning DisabilityOther (please state)
If other please state

I confirm that all information I have provided is current and accurate to the best of my knowledge.
I Confirm

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