Southwark Adult Learning Service

External Groups 2009/10

Enrolment Form and Learning Agreement

Please complete this form in BLOCK CAPITALS.

If you need help in completing this form please seek assistance from a member of staff.

Personal Details:
Title(please circle) / Other / Last name
Mr / Mrs / Ms / Miss / First name(s)
Full address
Postcode / Telephone
Email address / Date of birth
D / D / M / M / Y / Y / Y / Y
male / female / Contact in case of emergency / name
telephone
We require the following information for funding purposes:
a) / How long have you lived in the UK? How many / years / months Or whole life
b) / If you have lived outside the UK in the last 3 years, please tick any of the following that apply to you: / Office use: evidence must be photocopied, signed & dated by member of staff who saw it, and attached to this form.
British or EU passport holder / Granted leave to remain indefinitely
Resident on student or visitors visa / Asylum seeker or refugee
Other, please specify
Equal Opportunities Monitoring: What is your ethnic origin?(Please tick the appropriate box)[L12]
11 / Asian or Asian British - Bangladeshi / 19 / Mixed – White and Asian
12 / Asian or Asian British - Indian / 20 / Mixed – White and Black African
13 / Asian or Asian British - Pakistani / 21 / Mixed – White and Black Caribbean
14 / Asian or Asian British – any other Asian background / 22 / Mixed – any other Mixed background
15 / Black or black British - African / 23 / White - British
16 / Black or black British - Caribbean / 24 / White - Irish
17 / Black or black British – any other Black background / 25 / White – any other White background
18 / Chinese / 98 / Any other
99 / Not known / prefer not to say
Disabilities and learning difficulties: We would like to give you the support you need to attend our classes. Do you consider yourself to have a learning difficulty and/or disability and/or health problem?[L14]
1 / YES / 2 / NO / 9 / Prefer not to say
If yes, please select any that apply to you from the boxes below:
L15 / L16
01 / Visual impairment / 01 / Moderate learning difficulty
02 / Hearing impairment / 02 / Severe learning difficulty
03 / Disability affecting mobility / 10 / Dyslexia
04 / Other physical disability / 11 / Dyscalculia
05 / Other medical condition (e.g. epilepsy, asthma, diabetes) / 19 / Other specific learning difficulty
06 / Emotional / behavioural difficulties / 90 / Multiple learning difficulties
07 / Mental ill health / 97 / Other
08 / Temporary disability after illness (e.g. post-viral) or accident / 98 / No learning difficulty
09 / Profound complex disabilities / 99 / Not known / prefer not to say
90 / Multiple disabilities / It may be helpful for your tutor to have this information. Are you happy for this information to be passed onto them?
97 / Other
98 / Not known / prefer not to say / YES / NO
You may wish to discuss your needs with your tutor so we can make reasonable adjustments to support your learning.
What is the highest level you have achieved in your previous learning?[L35]
09 / Entry level
07 / Other qualifications below level 1
01 / Level 1:GCSE / O levels grades D-G, CSE below grade 1, GNVQ foundation level, NVQ level 1
02 / Full level 2:GCSE / O levels grades A-C, CSEs grade 1, GNVQs Intermediate, NVQ level 2
03 / Full level 3: 2 or more A levels, 4 or more AS levels, GNVQ advanced
04 / Level 4: Teaching qualifications, degree, HNC or HND, NVQ level 4, Nursing SRN
05 / Level 5 and above: Higher Degree, NVQ level 5, Masters, doctorate
97 / Other qualification, level not known
98 / Not known
99 / No qualifications
How did you find out about this course?
In person or by phone / Friend or family member
Prospectus or leaflet / Local library
Other (please specify)
Please list the course(s) you want to enrol on / Organisation:
Course code / Course title / Learner’s start date / Planned end date / Venue

Data Protection Act 1998

The information you provide on the enrolment form will be passed to the Learning and Skills Council (the LSC). The LSC is responsible for funding and planning education and training for young people and adults in England, and is registered under the Data Protection Act 1998. The information you provide will be shared with other organisations for the purpose of administration, careers and other guidance, and statistical and research purposes. Other organisations with which we will share information include, the Department for Education and Skills, Connexions, Higher Education Statistics Agency, Higher Education Funding Council for England, educational institutions and organisations performing research and statistical work on behalf of the LSC or its partners. The LSC also administers the learner registration service (LRS) which will use your information to create and maintain a unique learner number (ULN). The LSC is also a co-financing organisation and uses European Social Funds from the European Union to directly or indirectly part-finance learning activities, helping develop employment by promoting employability, business spirit and equal opportunities, and investing in human resources. Further information about partner organisations and the ULN and what they do, may be found at and by following the links to data protection.

At no time will your personal information be passed to organisations for marketing or sales purposes. From time to time students are approached to take part in surveys by mail and phone, which are aimed at enabling the LSC and its partners to monitor performance, improve quality and plan future provision.

Tick this box if you DO NOT wish to be contacted by the LSC or its partners in respect of surveys and research. The LSC values your views on the education or training which you receive, and will use these to help bring about improvements for learners in England.

The LSC or its partners may wish to contact you from time to time about courses, or learning opportunities relevant to you. Please tick this box if you DO NOT wish to be contacted about courses or learning opportunities by post.

Student Declaration and Learning Agreement
  • I confirm that the information I have provided on this form is correct. I understand that I have signed up to attend the learning programmes detailed above. I undertake to attend regularly and punctually on all courses that I have enrolled for.

Student signature / date
Staff signature / date