Course Application Form Key Stage 4

Please complete all sections on this form and write in BLOCK CAPITALS.

  1. Course title
/ Course code / Enfield or Tottenham
  1. Personal Details

Title:
Mr / Ms / Miss / Mrs / Other / First name(s): / Family name / surname:
Male / female: / Date of birth: / Age you will be on 31 August 2016:
Address: / Postcode:
Home telephone: / Work telephone: / Mobile telephone:
Email address: / Please give the name of your current secondary school:
  1. Why do you want to do this course?

Please use this box to tell us about your reasons for doing the course, including your future job / career / university plans.
  1. Your qualifications

Name of school / college attended(most recent first) / Years attended / Subject / Course / Tutor to complete predicated grade / Grades obtained
From / To
  1. Your employment and experience

Are you employed? / Yes / No
Are you working as a volunteer? / Yes / No
Job Title: / Employer:
Address:
Postcode:
What experience and skills do you have that are relevant to your course? Include any paid / voluntary work and any responsibilities you have had.
  1. Please underline what best describes your ethnic group

White
English/Welsh/Scottish/ Northern Irish/British
Irish
Gypsy or Irish Traveller
Any other white background
Mixed/Multiple ethnic group
White and Black Caribbean
White and Black African
White and Asian Any other Mixed/multiple ethnic background / Asian/Asian British
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian Background
Black/African/Caribbean/Black British
African
Caribbean
Any other Black/ / Other ethnic group
Arab
Any other ethnic group
Not provided
What language do you speak at home?
  1. Support

We are committed to supporting people with learning difficulties, disabilities, mental health or other support needs.
Do you have a learning difficulty or disability? / Yes / No
If you have answered yes, please underline the relevant difficulty/disability below.
If you have a mobility difficulty or visual impairment we need to know so that we can protect your health and safety, e.g. in case of emergency exit.
Learning difficulty:
Autism spectrum disorder (20)
Dyscalculia (11)
Dyslexia (10)
Moderate learning difficulty (01)
Multiple learning difficulties (90)
Severe learning difficulty (02)
Other specific learning difficulty (19)
Other (97) – please describe below / Disability:
Asperger’s syndrome (10)
Blind / serious visual impairment (01)
Deaf / hearing impairment (02)
Emotional, behavioural difficulties (06)
Mental health difficulty, e.g. depression, serious anxiety (07)
Mobility difficulty (03)
Multiple disabilities (90)
Profound complex disabilities (09)
Other physical disability (04) / Other medical condition, e.g. asthma, diabetes, epilepsy, sickle cell (05)
Temporary disability after illness, e.g. post viral or accident (08), please describe below
Other (97) – please describe below
Will you need support for your learning difficulty / disability? / Yes / No
Do you have a statement of special educational needs? / Yes / No
  1. How did you hear about the course? Please underline.

I study at the College
College website
Internet searches
Hotmail courses
Facebook
Twitter
Text message
Email
I saw the College building/banner / Course Guide
Open Day
Poster: shopping centre
Poster, bus
Poster, tube
Leaflet handed out on street
Leaflet to my home
Newspaper/Magazine advert
Friends/family / At my school
Careers Adviser/Connexions
Employer
Trade Union
Job Centre
Library
Radio advert
Other, please specify
  1. Signature

I confirm that the information I have given in this form is correct. I give my consent to the College of Haringey, Enfield and North East London to record and process this information, on the understanding that the College complies with the Data Protection Act 1998.
Signature of applicant: / Date:
  1. Reference

Please make sure your most recent school/college fills in this section in full. Completed application forms must include a reference, usually from a school or college form tutor, head of year or another teacher who knows you well. If you have left school you can ask an employer or Connexions advisor to fill in this section. We are unable to process any forms which do not include a reference.
Name of Applicant: / School / College:
Attendance: (please provide actual numbers) / Number of days absent: / Out of how many possible school days:
Punctuality: / Good / Fair / Poor
Were there any extenuating circumstances for poor attendance?
Support Needs (please select):
English Language / Pastoral / Medical / Learning
Recommended course level for the applicant (please select):
Entry Level / Level 1 / Level 2 / Level 3
Did the applicant receive additional support at school? / Yes / No
If yes, please give details and tell us what support was needed (including help with exams)
Has the applicant received any targeted support from either your staff or other agencies? / Yes / No
In your written statement please tell us: whether the applicant is likely to succeed on the course(s) and at the level they applied for, the applicant’s strengths, achievements and where they need to improve: any particular responsibilities: their relationships with tutors and peers: how organised they are in meeting work deadlines.
Signed for the school/employer: / Name:
Position: / Date:

PLEASE CHECK THIS LIST BEFORE SENDING FORM
Applicant: School:

Signed form Signed form

School stamp Completed attendance and punctuality

Completed predicted grades

Please return your completed Application Form to:

The College of Haringey, Enfield and North East London, Tottenham Centre, High Road, London, N15 4RU