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Mentoring self-referral form

Apply for the Unchained mentorship programme

Date of birth
Month
Day
Year

Have you ever applied to or taken part in Unchained mentorship/workshop programmes before?

Please choose
Yes
No

When were you convicted?

Date
Month
Day
Year

What are your convictions for? Please list ALL convictions here:

How long is/was the sentence?

Are you still serving a sentence or have you been released?

Please choose
Still serving a sentence
I've been released

What is your ethnicity?

Please choose
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background
Caribbean
African
Any other Black, Black British, or Caribbean background
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed or multiple ethnic background
English, Welsh, Scottish, Northern Irish or British
Irish
Gypsy or Irish Traveller
Roma
Any other White background
Arab
Any other ethnic group

Do you think your race or ethnicity played a part in the length of your sentence?

Please choose
Yes
No
I don't know

What was your life like before prison?

What factors do you think led to your conviction or being involvement in crime?

What do you want to achieve from the project?

Have you ever performed live anywhere other than at an Unchained night?

Please choose
Yes
No

How does writing or performing poetry, rap, bars, or lyrics help you tell your story?

What do you want to achieve from sharing your story?

How confident are you with sharing your story with the public?

Please choose
I don't want to
I'm not confident
I'm not sure
Fairly confident
Very confident

Are you on any benefits?

Please choose
Yes
No

Please give us any other information you think would be relevant or helpful to us

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