Application form (PDF) - Bexley College

Learning Programme
Application Form 2012/13
Please complete this form in BLOCK CAPITALS
and return to: Admissions, Bexley College, Tower Road, Belvedere, Kent DA17 6JA.
Email courses@bexley.ac.uk
Course Title
Course Code
2 nd Choice Course Code
Mode of Study Full time study (3-5 days per week at College) Part Time study Apprenticeship
Last name (s) First name Title
Home Address
For Office Use only:
Date of Birth Gender Male Female Home Telephone
National Insurance Number
Postcode
Mobile Number
Residency
Residency
E-mail Address
Have you been permanently resident in the UK or EU for the past 3 years? Yes No
Is there any restriction on the time you may stay in the UK? *Yes No
If * box ticked please provide brief details of how long you have been resident in the UK and the circumstances of your arrival and stay
in the UK: (asylum seeker, marriage etc..)
What is your first language?
Do you need extra support for English as a second language? Yes No
Please state Nationality
Support at Bexley College
Support at Bexley College
By giving the College information about your disabilities or health needs, you will not be affecting your chances of getting
on the course in any way. The information you provide will be shared with your teaching staff to make sure you get the
support you need. For further information see our Disability statement.
Please tell us if you need any support for any of the following? Blind/Visual Impairment
Speech Difficulties Wheelchair user Other mobility needs Dyslexia
Mental Health Autism Aspergers Dyscalculia
Other (please specify)
Deaf/Hearing Impairment
(e.g. epilepsy, diabetes, asthma)
Please give details of any further assistance or equipment you would require whilst at the College or for your
assessment/interview stage (e.g. large print or sign interpreter)
Did you have a statement of special educational need while you were at school? Yes No
If yes, when was this dated?
Choice of course
Briefly, tell us your reasons for choosing this course:
v

Qualifications on Entry
Please list below all the qualifications you have or will be taking. Make sure that you fill in expected grades where
applicable as these details will help us to place you on the most suitable course.
Subject/Course
Type of exam
(e.g. GCSE)
Date of exam Predicted Grade Grade achieved if
exam already taken
Please give us details of your School, College or most recent employer
School/College/Most recent Employer name
School/College/Most recent Employer address
Dates you attended School/Employment: From / To /
mth year mth year
Reference Details
If you aged between 16 – 18 years you will need to bring to the interviews your most recent school report, predicted or actual
GCSE results and your School record of achievement.
Ethnic Origin
In order to help us monitor equal opportunities. Please indicate your ethnic origin by selecting from the following choices.
31 White – English/Welsh/Scottish/Northern Irish/British 32 White – Irish 33 White – Gypsy or Irish Traveller
34 White – any other White background 35 Mixed/Multiple ethnic group – White & Black Caribbean
36 Mixed/Multiple ethnic group – White & Black African 37 Mixed/Multiple ethnic group – White & Asian
38 Mixed/Multiple ethnic group – Any other Mixed/Multiple ethnic background 39 Asian/Asian British - Indian
40 Asian/Asian British - Pakistani 41 Asian/Asian British – Bangladeshi
42 Asian/Asian British – Chinese 43 Asian/Asian British – Any other Asian Background
44 Black/African/Caribbean/Black British- African 45 Black/African/Caribbean/Black British – Caribbean
46 Black/African/Caribbean/Black British – Any other Black/African/Caribbean background 47 Other ethnic group – Arab
48 Other ethnic group – Any other ethnic group 98 Any other (please state)
99 Not Known/Not Provided
eclaration/Consent to Process
Declaration/Consent to Process
Data collected on this form may be computerised. It is used both for statistical purposes within the College and it’s Funding
bodies and for sharing analysis with Schools, Colleges, Funding bodies and Local Authorities.
I confirm that the information provided on this form is correct to the best of my knowledge and consent to this data being used
above:
Signature of Applicant Date Date
If the Applicant is under 18:
I agree with this application to the College and will ensure compliance with the College Regulations.
Parent/Guardian signature:
Name:
Thank you for completing this Application Form. We will contact you in due course to arrange an interview with your Course
Tutor (if necessary) and you may also be asked to take a short aptitude test. All the information on this form will be held subject
to the terms of the Data Protection Statement for 2012/2013 and will only be passed to Government Departments and Agencies
for statistical record purposes. All data is held in accordance with the Data Protection Act. By signing this form you agree all the
data supplied is correct.
Date