Form 4 Students Registration – Richmond Foundation

NAME AND SURNAME*

I.D. NO:*

DATE OF BIRTH:*

DD

MM

YYYY

PERSONAL ADDRESS:*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code

NAME AND SURNAME OF PARENT / GUARDIAN:*

ID NUMBER OF PARENT / GUARDIAN:*

EMAIL ADDRESS (of student or of parent/guardian) :*

MOBILE NUMBER (of student or of parent/guardian) :*

AGE GROUP*

GENDER (As per ID card)*

Male
Female

Mark your Lesson Group*

Mark where you will take the lessons on mental health first aid. (mark you school)

RESIDENCE (As per ID card)*

Malta
Gozo

NATIONALITY*

YES
NO

Are you a migrant, a person with a foreign background or minorities (including marginalised communities such as the Roma)?

EDUCATIONAL BACKGROUND*

Currently in Form 4

Are you a disabled person?*

YES
NO

Are you enlisted in one of the following*?*

YES
NO

* A registries: (i) Commission for the Rights of Persons with a Disability; (ii) social security for the participants benefiting from disability benefits; (iii) Jobs Plus?

If you marked yes in the previous question, please write your registration number and entity with which you are registered:

Do you have any other disadvantages?*

YES
NO

Tick yes if one or more apply: (i) ISCED level 0; (ii) homeless or effected by housing exclusion); (iii) inmates or former offender; (iv) former substance abusers or undergoing detoxification treatment; (v) at risk of poverty.

Do you live in a single adult household with dependent children?*

YES
NO

Are you living in the following circumstances: rooflessness, houselessness, insecure accommodation, and/or inadequate housing?*

YES
NO

Download the Terms and Conditions using the link below, print, sign, scan or take a photo and upload*

Download T&C