Islington Housing Services in partnership with London Metropolitan University delivering an accredited course on housing issues

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1 Islington Housing Services in partnership with London Metropolitan University delivering an accredited course on housing issues Please return the completed form by Wednesday 22 June 2013, 10.00am Application Form Title (please circle) Mr Mrs Ms Miss Other. Full Name Address and post code Telephone Home: Work: Mobile: Current status (Employed /Retired/ Unemployed/Student please provide details)

2 Please provide a written statement of no more than 300 words to outline why you wish to apply for a place on the accredited mini module course on housing issues. Please read the introduction to the course, course outline and time commitment and confirm in your statement that you are able to meet the requirements that are necessary for participating in this course. (Please continue on one page of A4 paper if you wish to): Are you a Islington Council (please circle): Tenant or Home Owner Please confirm that you will be able to attend all 3 sessions on 10, 18 & 24 June 2013 plus attend a day s work experience with Islington Housing Services Signed Date

3 Equal Opportunities & Diversity Monitoring To help us monitor if there are any particular individuals, groups or communities that we are not reaching please complete the below diversity information. Islington Council has identified six key equality strands: race; gender; disability; age; religion or belief; sexuality that we would like to know about. The information you provide on this form will be used by Islington Council only and for monitoring purposes of ensuring equality of opportunity for all. If you would prefer not to disclose some information, please tick the "prefer not to say" box provided. Any information that you do provide to Islington Council will be protected by the Data Protection Act Thank you in advance for completing this form. Name:. Age:.. Date of Birth:. Gender: Male Female Transgender Ethnicity: Please tick the box which you think best describes you (tick only one): Asian or Asian British Bangladeshi Indian Pakistani Other Asian Mixed White and Asian White and Black African White and Black Caribbean Any Other Mixed Black or Black British Caribbean African: Eritrean Ghanaian Nigerian Somali Other African Other Black Chinese or other Ethnic Group Chinese Filipino Vietnamese Any Other ethnic group White British Irish Greek/Greek Cypriot Kurdish Turkish/Turkish Cypriot Any Other White If you selected any of the "Any Other" categories, please specify below how you would further describe yourself.

4 Religion or belief: Please tick the box which you think best describes your religion or belief (tick only one): No religion or belief Buddhist Christian Hindu Humanist Muslim Jewish Rastafarian Sikh Other religion or belief (please specify). Sexual Orientation: Please tick the box which you think best describes your sexual orientation (tick only one): Bisexual Gay Heterosexual Lesbian Disability Under the Disability Discrimination Act 1995 you are considered to have a disability if you have 'a physical or mental impairment which has a substantial and long term adverse effect upon your ability to carry out normal day to day activities'. People who have had disabilities in the past are included. Progressive conditions, such as cancer, multiple sclerosis, muscular dystrophy and HIV infection, are covered by the Act from the moment the condition has been formally diagnosed. Physical and mental impairments include sensory impairments, such as those affecting sight or hearing, learning disabilities, and clinically well recognised mental illness.

5 Substantial adverse effect is more than a minor or trivial effect and goes beyond the normal differences between people. Substantial effects of a disability, which has ceased but is expected to recur at least once a year, for example rheumatoid arthritis or epilepsy, are included in the definition. Long-term effect is one, which has lasted, or is likely to last, 12 months or more. Normal day to day activities are those which are carried out by most people on a fairly regular and frequent basis. An impairment has a substantial adverse effect if it affects: Ability to lift, carry or otherwise move everyday objects Mobility Speech, hearing or eyesight (excluding those Manual dexterity who wear glasses/contact lenses) Physical co-ordination Memory or ability to concentrate, learn or Continence understand, or Perception of the risk of physical danger Do you consider that you have a disability under the Disability Discrimination Act definition? Yes No If you have indicated that you have a disability, please select the definition(s) from the list below which best describe your disability/disabilities. (please tick) Hearing Severe disfigurement Vision Learning difficulties (e.g. dyslexia) Speech Mental illness Mobility Physical co-ordination Other disability, please specify Please return all sheets in the pre-paid envelope provided by 18 July We will now conduct eligibility checks against the eligibility criteria detailed in the application pack and will be in touch with you thereafter. Good Luck!

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