Academic Year Casework Internship Application 2017 Equal Opportunities In order to help us monitor the effectiveness of our equal opportunities policy, we ask all internship applicants to provide the information indicated below. This information will only be used for monitoring and statistical purposes. Ethnic origin I would describe my ethnic origin as: A) White B) Mixed C) Asian English White & Black Caribbean Indian Scottish White & Black African Pakistani Welsh White & Asian Bangladeshi Irish Other Mixed: ____________ Chinese Other White: Other Asian: _____________ ______________ D) Black E) Other F) Would prefer not to indicate Caribbean Any other ethnic background, please African describe: ______________ Other Black: _______________ Age Date of birth: Would prefer not to indicate Disability Do you consider yourself to have a disability? Yes No Would prefer not to indicate If yes, please tick any of the list below which apply. Dyslexic Need personal care Multiple difficulties Blind / partially sighted Mental health difficulties Other: ____________________________ Deaf / hearing impairment Unseen disability (eg asthma, diabetes, Would prefer not to indicate Wheelchair use / mobility epilepsy difficulties
Academic Year Casework Internship Application 2017 Equal Opportunities In order to help us monitor the effectiveness of our equal opportunities policy, we ask all internship applicants to provide the information indicated below. This information will only be used for monitoring and statistical purposes. Ethnic origin I would describe my ethnic origin as: A) White English Scottish Welsh Irish Other White: ______________ B) Mixed White & Black Caribbean White & Black African White & Asian Other Mixed: ____________ C) Asian Indian Pakistani Bangladeshi Chinese Other Asian: _____________ D) Black Caribbean African Other Black: _______________ E) Other Any other ethnic background, please describe: ______________ F) Would prefer not to indicate Age Date of birth: Would prefer not to indicate Disability Do you consider yourself to have a disability? Yes No Would prefer not to indicate If yes, please tick any of the list below which apply. Dyslexic Blind / partially sighted Deaf / hearing impairment Wheelchair use / mobility difficulties Need personal care Mental health difficulties Unseen disability (eg asthma, diabetes, epilepsy Multiple difficulties Other: ____________________________ Would prefer not to indicate
Academic%20Year%20Casework%20Internship%20Equal%20Ops%20Form%202017.docx