Cycle Into Work Referral/Enquiry Form

Use this form to refer yourself or someone to the Cycle Into Work programme, or if you have a general enquiry.

If referring someone else, please make sure they have given permission to be contacted by us and note that all information will remain confidential and only be shared on a need-to-know or anonymised basis.

Applicant Name (required)

Applicant Phone Number (required)

Applicant Email Address

Applicant Borough (required)

Are you enquiring for yourself or referring someone else to the Cycle Into Work Programme? (required)

If booking on behalf of yourself- were you referred to this program by someone else? (required)

YesNoNA

If Yes Who referred you (eg Job Centre, Housing association)?

If booking on behalf of yourself - Are you currently unemployed? (required)

YesNoNA

If Yes How long have you been unemployed?

If you are referring someone else: Your Name (Write "NA" if you are applying for yourself) (required)

If you are referring someone else: Your Phone Number If you are referring someone else: Your Name (Write "NA" if you are applying for yourself) (required)

If you are referring someone else: Do we have permission from the person to be contacted directly? (required)

YesNoNA

If referral for someone else: Your organisation name (Write "NA" if you are applying for yourself) (required)

If referral for someone else: Do you think the person can complete a virtual interview themselves or will they need support?

If referral for someone else: Type of Referral (Select "NA" if you are applying for yourself) (required)

Demographic information for Participant (If booking on behalf of someone else answer to the best of your knowledge or select “Prefer not to say” and participant will be asked directly if they wish to give this information)

Age (required)

Gender (required)

Please describe any learning difficulties, disabilities, or sensory needs here. (required)

Please type your question/comments/message here

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