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Please complete all sections in BLOCK CAPITALS as this information will be used to create an electronic learner record, should you choose to start a programme of learning with us. Ensure you sign the declaration on page 5.

If you require any assistance or clarification with completing this application, please contact us:

Call: 01922 214333Email:

Please state the occupational area/programme of learning you are interested in: (e.g. IT, Literacy)
SECTION 1: PERSONAL DETAILS
Title First Name(s) Last Name
National Insurance Number Date of Birth Gender
- / - / - / - / Male
Female
If you have not yet been issued with a national insurance number you will need this at the point you start a programme.
Please tick the box that describes your ethnic origin
White / Mixed/Multiple Ethnic Group / Asian/Asian British / Black/ African / Caribbean/ Black British / Other Ethnic Group
31  English/Welsh/Scottish/
Northern Irish / British
32  Irish
33  Gypsy or IrishTraveller
34  Other white background / 35 White & Black
Caribbean
36  White & BlackAfrican
37  White & Asian
38  Other mixed/multiple
ethnic background / 39  Indian
40  Pakistani
41  Bangladeshi
42  Chinese
43  Other Asian
background
44  African
45 Caribbean
46  Other Black/African /
Caribbean background / 47  Arab
98  Otherethnic
group
99 Not provided
Where ‘Other’box has been ticked, please give details:
In order to assess your eligibility for possible funding, we need details on your residency status and length of time you have lived in the UK. Temporary absences from the UK should be ignored. If you have not been resident because you, or your parent or spouse were working temporarily abroad, you will be treated as though you have been ordinarily resident in the UK.
Where were you born? (Please state country)
How long have you lived in the UK and islands?(please tick the appropriate box)
 Since birth  More than 3 years  Less than 3 years
Did you enter the country as a dependent?
Has any time during the last 3 years been spent in full-time education?
Current Permanent Home Address Postcode
Home Telephone Number
Personal E-Mail Address Mobile Telephone Number
How long have you lived at the above address? / Years / Months
If less than 3 yearsrecord your previous address(es) during the last 3 years (including addresses outside the UK)
Address / Post Code (if UK) / Country / Dates from and to
SECTION 2: QUALIFICATIONS AND TRAINING
Are you currently studying any qualifications? / If YES please give details
Organisation Studying With: / Qualification Being Studied: / Start Date: / Expected Finish Date: / Funded By: / Hours
Per Week:
QUALIFICATIONS
  • Please list ALL qualifications and certificates gained (e.g. GCSEs, A’ Levels, Degree, O’ Levels, GNVQs, Apprenticeships, NVQs, Key Skills, etc.) including those gained at school.
  • Also list any certified training undertaken.
  • Your Personal Learning Record, where available, will also be accessed by us to verify qualifications.

Organisation / Qualification Title/Certified Training / Grade or Level Achieved / Date Achieved
e.g. Wood Green High School / ‘O’ Level English Language / C / June 1984
If you are aged 16-19, what date did you leave Year 11? Month / Year
Have you worked towards, but not completed, any qualifications with another provider/college?
If YES, please give details
Provider/College Name: / Qualification Studied: / Dates To and From:
SECTION 3: SUPPORT IN LEARNING
Do you think you may need support with English or Maths?
If YES, please give brief details
Do you consider yourself to have a disability, learning difficulty and / or health problems?
If YES, please tick whichever applies to you (you can tick more than one category)
04visual impairment
05hearing impairment
06disability affecting mobility
07profound complex disabilities
08social and emotional difficulties
09mental health difficulty
10moderate learning difficulty
11severe learning difficulty
12dyslexia
13dyscalculia (difficulty with numbers) / 14autism spectrum disorder
15aspergers syndrome
16temporary disability after illness (e.g. post viral) or accident
17 Speech, language and communication needs
93other physical disability
94other specific learning difficulty(e.g. dyspraxia)
95other medical condition (e.g. epilepsy, asthma, diabetes)
96other learning difficulty
97 other disability
98prefer not to say
If you have ticked more than one category, please state the ONEthat you consider to be your main or most significant disability, learning difficulty or health problem that affects education.
Please indicate below if any health issues affect the type of work or training you can undertake:
The Disability Discrimination Act 1995 defines a disabled person as someone who has a physical or mental impairment which has a substantial and adverse long-term effect on his or her ability to carry out normal day-to-day activities.
Do you consider yourself to be a disabled person?
Local Authority Support
Are you currently being supported by the Local Authority (e.g. living under Local Authority care, you
are a care leaver, you have a Learning Difficulty Assessment, or Education HealthCare Plan)*
If YES, please give brief details
* Any information you provide will be treated in confidence and used to ensure you receive the support to which you are entitled.
By declaring this information you agree to us liaising with appropriate external organisations to support you where appropriate.
SECTION 4:LEARNING STYLES
We would like to learn a little about how you learn. For each question on the left, please circle either A, B or C to indicate which statement most represents how you generally behave. Your Interviewer will discuss the results with you.
QUESTIONS / INITIAL INDICATIONS
When operating new equipment you prefer to / Mainly A’s -
Your preferred learning style may be VISUAL
You will remember things best when you've seen them. You will like a stimulating and orderly environment. You probably like to use diagrams and charts. You probably like reading, and may be a good speller. You learn best when visual aids are used such as displays, posters etc and need to be able to see the tutor in a classroom situation.
A / Read the instructions first
B / Listen to an explanation from someone
C / Go ahead and have a go (you’ll figure it out as you use it)
During your free time you most enjoy
A / Going to museums and galleries, or watching films
B / Listening to music and socialising with friends
C / Playing sports, doing D.I.Y, cooking etc
If you were buying a new car you would initially / Mainly B’s –
Your preferred learning style may be AUDITORY
You will learn best when you're listening (for example, in a lecture) and when you're involved in discussion. You will probably remember things best when you've listened to the instructions from an expert. You learn best when you talk things through, reciting facts or even singing them aloud, and may learn better with certain background noise such as music, or require silence to concentrate.
A / Read reviews
B / Listen to recommendations from friends
C / Test drive lots of cars
When you are learning a new skill, you are most comfortable
A / Watching what the tutor is doing
B / Talking it through with the tutor
C / Giving it a try yourself (work it out as you go)
When you concentrate you most often
A / Focus on the words/pictures in front of you
B / Discuss the issue and possible solutions in your head / Mainly C’s –
Your preferred learning style may be KINAESTHETIC
You will learn best when you're moving around. You will remember things best when you've done them (rather than just read about them). You may have trouble with spelling. You learn best when you can move around, you can work through problems physically, when you can use models, games and role play etc. and think over what you’ve learned whilst doing something else like swimming etc.
C / Move around a lot, pick up/hold things
You remember things best by
A / Writing notes or keeping printed details
B / Saying them aloud or repeating key points in your head
C / Doing and practising the activity
Having met someone new, you are most likely to remember
A / Faces
B / Names
C / Things you have said and done
This exercise is used as a guide only. Your interviewer will talk through your results with you and give you information on how to investigate your learning styles further.
SECTION 5:ABOUT YOUR EMPLOYMENT
Employment Status
Please indicate your current employment status and follow the instructions
I amregistered as unemployed at Job Centre Plus (JCP) local office______(complete Part A)
I am unemployed, looking for work but not registered with Job Centre Plus (JCP) (complete Part A)
I am in paid employment/self employment (complete B and C)
Part A
If you are unemployedor registered as unemployed with Job Centre Plusplease complete this section
What state benefit are you receiving?(BSI)
Job Seekers Allowance(JSA) or NI creditsEmployment Support Allowance in Work Related Activity Group(ESA WRAG)
Universal Credits Other (please state) ______
None
How long have you been unemployed/registered as unemployed with JCP?(LOU)
Less than 6 mths 6-11 mths 12-23 mths 24-35 mths 3 years or more
Are you taking part in a JCP ‘Work Programme’?
Yes No If Yes, please state the training provider name: ______
Are you doing any paid work, volunteering in a company, or attending an unpaid work placement?
Yes No If Yes, please give placement details in the ‘Current Employer/Placement Details’ sectionbelow (Part C)
Part B
If you are in paid employment please indicate the type of employment
I am employed by the company detailed below (Part C) and have a Permanent contract of employment
Please tick one: I am in secure employment or I am threatened with redundancy
I am employed by the company detailed below (Part C) and have a Temporary contract of employment.
My contract end date is: / / /
I am Self Employed/Sole Trader (since ...... mth/yr) and registered with the HM Revenue and Customs
I am employed by an Agency on a long term assignment to the company detailed below (Part C).
My contract end date is: / / /
Part C
Current Employer / Placement Details
Company Name What is your Job Title?
Company Address
Who do you report to (name)?
Postcode
Please indicate the length of employment in this company (LOE) or confirm your non-employed status
3 mths or less 4 to 6 mths 7 to 12 mths 13 mths to 35 mths 3 yrs or more OR Not employed
Company Telephone Number / Company E-mail
Days you work / Pattern of Hours
Number of hours you work per week (do not include overtime)
Describe the main aspects of your job role
Employment History
We require your employment history for the last 3 years. Complete this section if:
  • You have worked at your current Company for LESS THAN 3 years (as indicated in Part C)
  • You have been unemployed for LESS THAN 3 years (as indicated in Part A)
Please supply the details of your previous employers and/or periods of unemployment during the last 3 years
Company Name (or state unemployed) / Job Title (if employed) / Dates of Employment/Service/unemployment (from and to)
SECTION 6: ADDITIONAL INFORMATION
What are your hobbies/interests?
Are you legally entitled to work in the UK? (We are legally obliged to seek this information under the Asylum and Immigration Act 1996, and you may be asked for proof of this)
Do you have any other information you wish to declare that may affect the type of environment you work in or training/work you can undertake (e.g. criminal records, behavioural issues)?
Please see notes on Safeguarding
If YES, please give brief details

Equality and Diversity: We strive to offer equality of opportunity and as part of our policy we monitor applications. Our aim is to ensure applicants are not discriminated against, either directly or indirectly. We value your background and experiences and we aim to meet your needs andexpectations wherever possible. Our aim is to create a learning environment which reflects, respects and values diversity.

Safeguarding: Weare committed to fulfilling our responsibilities and promoting the welfare of all learners. Please help us by providing all information that may affect you and those around you. Where we are responsible for placing you with a suitable employer, you may be required to obtain necessary DBS checks where you will be working with children or vulnerable adults. This may include the disclosure of criminal offences that have been ‘spent’.

Data Protection: We are registered under the Data Protection Act and as required by that legislation, we follow strict handling and security procedures in the storage and disclosure of information you have given us to prevent unauthorised access or misuse.

The information held on your Personal Learning Record (where available) will be used to help us provide you with information, advice and guidance, unless you indicate otherwise. If you need more information about this record please speak to your provider contact or visit the National Careers Service website. Should you start a funded programme, the information on this Form will be used as per the statement below and you will be asked to indicate your preferences in how your information is used.

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Version 4.0 Aug 16