100 Black Men of London

Personal details

Title

First Name *

Last Name *

Address * Line 1

Address Line 2

Post Code *

Telephone *

Gender

Female
Male
Other

Are you over 49 years old?

Yes
No

Do you live alone?

Yes
No

Are you applying for this programme because you feel isolated or lonely?

Yes
No

Consent

You have the right to know how we use your personal information. It is important that you read the information below before you sign. All participants in Business in the Community's ClickSilver Connections programme should be aware that by providing the information contained within this form, you consent to Business in the Community holding this information confidentially for the purpose of processing your application and evaluating the effectiveness of our programmes. You should also be aware that we will share this information with your business mentor in order to gain the maximum benefit from your participation. Participants who do not have access to a pc, laptop, smartphone or tablet should be aware that BITC will need to share your name and full postal address with Capital One, the programme sponsors, in order for them to be able to send you a device should one be available. Any personal data shared in relation to the ClickSilver programme will only be used for the purposes of enabling the ClickSilver programme and not for any commercial purposes. For research and monitoring purposes, your individually identifiable data will be held on our system for a period of 6 months, after which time all personal data will be deleted – however we will still retain anonymised information to allow us to track the impact of the programme. When sharing positive outcomes and case studies, we will always anonymise who it belongs to, unless we gain your permission to use your details. At any point during or following your involvement with ClickSilver Connections, you have the right to request information we hold about you, we call this Right to Access. All requests will be dealt by the Programmes Team alongside the National Data Protection Officer. Declaration of consent I consent to all of the information which I disclose on this form (including sensitive information relating to my physical or mental health) being used and shared for the purposes set out in the data protection statement above. I understand that if it is subsequently discovered that any statements from me are false or misleading, I may no longer be eligible for the programme. *

I give consent

100 Black Men of London

Personal details

Equal opportunities