Please complete this form in BLACK INK and in BLOCK CAPITALS

KS4 Application Form for September 2016

  1. Personal Details

Surname: / Forenames:
Date of Birth (dd/mm/yyyy): / Gender (please tick): Male Female
Home Address:
Post Code:
Home Telephone / Student Mobile Telephone:
Student Email Address:
Nationality:
Are you either an asylum seeker or a refugee or do you have Humanitarian Protection (HO) or Discretionary Leave to Remain (DL): Yes No
Is English your first language? Yes No / Have you ever lived outside the UK (excluding holidays of 3 months or less)? Yes No
If YES please give details:
Country / Dates
From / To
  1. Current (or most recent) School

3. Current (or most recent) CoursesPlease list the subjects and qualifications you are studying (or have achieved) at your present (or most recent) school and give predicted grades from your teachers and/ or actual results awarded.
Subject / KS3 Level / Subject / KS3 Level
4. Additional Learning Support
Do you have a disability, learning difficulty or problems with literacy or numeracy? / Yes
No (please continue to section 5)
What form does this take? (You do not have to disclose this information. However, if you do, this will help us prepare the support that you may need. Any information you provide will be treatedconfidentially).
5. Criminal ConvictionsYou must disclose certain, specific convictions
Do you have any relevant, unspent criminal convictions? Please specify.
6. Parent/Carer or Emergency Contact
Title: Mr Mrs Ms Miss / Full Name:
Address (if different from your own):
Daytime Telephone: / Mobile Telephone:
Email Address:
7. Medical Contact Information
Doctor’s Name: / Telephone Number:
Doctor’s Address:
Details of any special medical information (or enclose a confidential letter)
8. Ethnic OriginPlease tick the most appropriate box that you would use to describe your ethnic origin
White: English/Welsh/Scottish/Northern Irish/British / Asian/Asian British: Indian
White: Irish / Asian/Asian British: Pakistani
White: Traveller / Asian/Asian British: Bangladeshi
White: Any other white background / Asian/Asian British: Chinese
Mixed/multiple ethnic group: White and Black Caribbean / Asian/Asian British: Any other mixed/multiple ethnic background
Mixed/multiple ethnic group: White and Black African / Black: African
Mixed/multiple ethnic group: White and Asian / Black: Caribbean
Mixed/multiple ethnic group: Any other mixed/multiple ethnic background / Black: Any other Black/African/Caribbean ethnic
background
Arab / Any other ethnic background
Not provided
9. Future PlansPlease outline any plans you have after studying the course you are applying for here, such as plans to study at a sixth form college, higher level, possible subjects, employment, training and career ideas
10. Choice of Subjects
Order of Preference / Course and Subject to be taken / Level 2 / GCSE
1st Choice / 1.
2.
3.
4.
5.
6.
11. Data Protection
Information you provide on this application form will be passed to the Education Funding Agency (EFA), which is registered under the Data Protection Act 1998. This registration is primarily for the collection and analysis of statistical data but it also allows the Agency to share information with other organisations for the purpose of detecting fraud. Further information about data confidentiality is available on request from BACA.
I agree to PACA/BACA requesting and sharing with my previous school(s) any relevant information which supports me in my wellbeing and educational progress.
We may ask you to help us with publicising PACA/BACA to future students. This could be in printed form, on the PACA?BACA website, as a photograph or video or as written information on your achievements. PACA/BACA will ensure decency and propriety will be maintained in any image used; no personal contact details will be given; an image will not be used beyond six years from the date of consent; PACA/BACA may share information with other persons for educational or promotional use. If you do not agree with this please tick this box:
12. Signatures
Signature of Student:
Printed Name: / Date:
Signature of Parent/ Carer:
Printed Name: / Date:
13. Office Use Only – PLEASE DO NOT COMPLETE ANYTHING ON THIS PAGE
App Received / Interview Date / Interview Time / Int. Letter Sent / Offer Letter Sent / Reply Remind Sent / Reference Requested / Special App. Sent
Input Data / Course Input / Withdrawn / ESOL Request / Fee Assess Required / Offer Accepted / Report/ Ref Seen / Interviewer
14. Choice of Subjects
Order of Preference / Course and Subject to be taken / Level 2 / GCSE
1st Choice / 1.
2.
3.
4.
5.
6.
15. Interviewer NotesPlease outline information on motivation, current progress, advice given about course choices, any possible changes of courses etc.
Attendance Percentage: Y8 Y9 / Action Plan Set? Yes No
Does the student require any form of additional support? Yes No
16. Interviewer Notes Please outline information on motivation, current progress, advice given about course choices, any possible changes of courses etc.
Status:
Firm Offer Made
Conditional Offer Made
Waiting List
No Offer Made
Percentage Likelihood of Enrolling:
Comments: