LEARNER

APPLICATION FORM

THIS FORM MUST BE COMPLETED BY THE APPLICANT

LEARNER NAME (Print)………………………………………………………………………(LN04/05)

(Please complete your name as you wish it to appear on any future certificates)

LN03 / LEAD PROVIDER ID / T / 0 / 0 / 0 / 9 / 0 / 3 / 6

PERSONAL DETAILS

Full Name ....………….…………………………...... ……..(Mr/Mrs/Ms/Miss) (LN04/LN05)

Address………………………………………………………………………...... (LN 6/7/8/9/10)

…………………………………………………Post Code ...... ………………………...... (LN11)

If you have not lived at the above address for the past three years, please provide your last address, including Post Code: …………………………………………………………………………………………………………………………

……………………………………………..…………………………………………………………………………..

Home Telephone Number ...... …..…………………………………….. (including area code)(LN12)

Mobile Phone Number…...... …....………………………………………

e-mail Address ......

(This is to enable us to obtain feedback during your training programme)

National Insurance Number ………………………………………….…………………...... (LN13)

Surname on 16TH birthday (if different to above)…...……………………………...... (LN14)

Date of Birth ……………....….. (LN15) Gender : MALE/FEMALE (LN16)

Country of Residence…. …………………….…………………………………...... (LP08)

Emergency Contact Name…………………………….TelephoneNumber…………………………

How did you find out about the Apprenticeship / Traineeship / Steps to Employment training programme (please tick)
/  School Careers Events
 Providers Open Days /  Providers Website
 Referred by another Provider
 Referred by Careers Wales / Job Centre Plus
Other, please Specify ......
LN17 / Ethnic Origin /  11 - White /  39 - other Asian background
(please tick one box only) /  21 - Black – Caribbean /  41 - mixed - White and Black Caribbean
 22 - Black – African /  42 - mixed - White and Black African
 29 - other Black background /  43 - mixed - White and Asian
 31 - Asian – Indian /  49 - other Mixed background
 50 - Arab
 32 - Asian – Pakistani /  80 - other Ethnic background
 33 - Asian – Bangladeshi /  90 - information refused
 34 - Chinese
LN18 / National Identity /  Welsh /  British
(please tick one box only) / English / other
Scottish / no response
Irish
LP23 / Welsh speaker
(please tick one box only) /  1 - fluent /  3 - not Welsh speaker
LP29 / Disability (self-
Assessed)
(please tick one box only)
/  91 - I consider myself to have a disability and/or learning difficulty which will impact on my learning /  98 - I consider myself to not have adisability and/or learning difficulty which will impact on my learning
LP30 /
Primary Type of Disability and/or Learning Difficulty which impacts ability to learn and/or use general facilities
(please tick one box only) /  21 - Visual impairment /  25 - Multi-sensory impairment /  29 - Severe learning difficulties
 22 - Hearing impairment /  26 - Autistic spectrum disorders /  30 - Profound and multiple learning difficulties
 23 - Physical and/or medical difficulties /  27 - Speech, language &
communication difficulty /  31 - Specific learning difficulties
 24 - Behavioural, emotional and social difficulties /  28 - Moderate learning difficulties /  91 - Does not apply
LP31 /
Secondary Type of Disability and/or Learning Difficulty
/  21 - Visual impairment /  25 - Multi-sensory impairment /  29 - Severe learning difficulties
(Where a learner has more than one type of learning difficulty and/or disability, a primary and secondary need should be recorded) /  22 - Hearing impairment /  26 - Autistic spectrum disorders /  30 - Profound and multiple learning difficulties
 23 - Physical and/or medical difficulties /  27 - Speech, language &
communication difficulty /  31 - Specific learning difficulties
(please tick one box only) /  24 - Behavioural, emotional and social difficulties /  28 - Moderate learning difficulties /  91 - Does not apply
LP56 / Work-limiting health condition
(This should be self-reported by the learner)
(please tick one box only)
/  1 - I confirm I have a work-limiting condition /  2 - I confirm I do not have a work-limiting health condition
School last attended (LN20)
/ DateLeftSchool(LN21)
DD/MM/YY
Was this a Welsh Medium School /  Yes /  No
Office use only-LN20: School last attended:
Name of College attended (Full time)
/ Dates
From To
DD/MM/YY DD/MM/YY
Did you attend college as part of the 14-19 Learning Pathways or Schools Link? YES / NO
If yes, what subject: …………………………………………………………………...
Previous Training
(with a different Training Provider) / Dates
From To
DD/MM/YY DD/MM/YY
Previous/Current Employment
(include part time or casual/summer) /
Dates
From To
DD/MM/YY DD/MM/YY
(Please State Job Title)

QUALIFICATIONS – from school/college/previous training (include all Key/Essential Skills and Level)

Type and Subject / Grade expected / Date due / Actual Results / Date Achieved / Certificate/Result Slip attached
LP57 / Lone parent indicator
(A lone parent is defined as a person with one or more dependent children (whether related to the children or not) living in a household with no other people. A dependent child is a person aged 0-15 or 16-18 and in full-time education)
(please tick one box only)
/  1 - I confirm I am a lone parent /  2 - I confirm I am not a lone parent
LP58 / Understanding Welsh indicator
(please tick one box only) /  1 – I am able to understand spoken Welsh /  2 – I am not able to understand spoken Welsh
LP59 / Reading / Writing in Welsh indicator
(please tick one box only) /  1 – I can read Welsh /  2 – I can write in Welsh /  3 – I can read and write in Welsh /  4 – I cannot read or write in Welsh

We will send some of the information we hold about you to the Welsh Government (WG). This information forms your learner record held by WG. The learner record held by WG is used by WG and the third parties detailed below for four broad purposes:

1. For WG, the Higher Education Funding Council for Wales, Estyn, and the Wales Audit Office to carry out their statutory functions.

2. For WG to produce anonymised data in statistical publications.

3. For third parties, such as further education sector bodies, to use anonymised data to carry out research or equal opportunities monitoring that WG deems to be in the public interest. This information may be published.

4. Occasionally WG may allow third parties acting on its behalf access to learner records including personal identifiers only to assist in linking learner records for the purpose of statistical research. Contractors will be required to sign confidentiality agreements in relation to the data, demonstrate that they operate satisfactory information security procedures, and destroy their copies of the data following conclusion of the research project.

Your contact details may be passed tosurvey contractors to carry out the Learner Voice Survey, or other surveys related to education functions on behalf of the organisations listed above. These contractors will use your details only for that purpose and will then delete them. If you do not want to take part in these surveys, please let us know.

Your rights: Under the Data Protection Act 1998, you have rights of access to the data WG holds about you. You may have to pay a small fee for this. For further information please email . For more detail on the above, please visit our website at

The data you supply will also be used by the Chief Executive of Skills Funding, to issue you with a Unique Learner Number (ULN) and to create your Personal Learning Record. It also means that information about your learning can be shared with others who have responsibility for your education and training. Further details of how your data is processed and shared can be found at If you do not wish to share this data, please tick here 

In signing this document, I acknowledge and agree that:

1.My personal data will be stored on a secure, external server to enable my data to be forwarded to the Welsh Government for funding and statistical purposed only; and

2.Personal data contained in this form may be processed for any legitimate purpose connected with my Apprenticeship and for a period following my Apprenticeship and/or for my Health and Safety whilst on an Apprenticeship programme.

Signed: ……………………………………… / Name: ………………………………………………. / Date: ……………………..
(To be dated and signed by the Learner) / (please print)

FOR OFFICE USE ONLY

Learner Registration Service - Type of Personal Identification provided

 Passport  Driving licence  ID card or other form of national ID  National insurance Card

 Certificate of Entitlement to Funding  Bank credit\Debit\card

NB: By not providing identification, or providing ‘Other’ identification – the learner will not be able to access their Personal Learning Record

 Other......

 None provided

Signed ……………………………………………… Name ……………………………………. Date ………………………

Staff evidencing identification provided

Medical Health Questionnaire

Full Name(s) …………………………..…………………………… Date of Birth ………………………….

If applicable: Course…………………………………………………….

The following information is required to ensure you are not placed in an environment or carry out tasks that may be harmful to your health. The information contained herein, is strictly confidential and will only be used for the purpose of assessing the suitability of you to particular jobs and/or environments. This will assist in identifying any problems before they occur. The answers given may not affect placing you with a training provider.

The client or person on behalf of the client must complete all relevant sections.

Do you have or are you aware of any disabilities?Yes No

If YES nature of disability: ………………………………………………………………………………………………

Do you or have you suffered from any of the following:
Bronchitis, Asthma or Chest Complaints?…………………………………..……………
Problems with your back?…………………………………………………..………………
Significant colour vision or other visual disability?………………………...……………
Hearing Defect?………………………………………………………………………………
Experience fits or fainting attacks?……………………………………………..…………
Epilepsy?………………………………………………………………………………....…….
Muscle or bone problems?……………………………………………………………....…
A learning disability, which might affect your ability to understand or act on instructions?......
Heart disease-affecting capacity for physical tasks?…………………………………
Skin disease (e.g. Eczema and Dermatitis)?………………………………………….…
Physically restricted from carrying out certain tasks?……………………………….…
Take prescribed medication?……………………………………………………………... / Tick Relevant Box
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Please supply further information if you have answered ‘Yes’ to any of the questions above

Please indicate any medication you may be taking

Medication - if known / Side Effects – if any

Do you suffer from any other medical condition not listed above, which you feel may affect you in the operation of your duties whilst on your learning programme?

Please enter details:

If your circumstances change, you must informyour Work Based Learning provider

Signed: ……………………………………… / Name: ………………………………………………. / Date: ……………………..
(To be dated and signed by the Learner) / (please print)

A01JUN11/12

Working in Partnership with CAVC