PRIVATE & CONFIDENTIAL
PERSONAL INFORMATION FORM
Queen Alexandra College is committed to ensuring that all applicants/students are considered and
treated on an equal basis. We ask all applicants/students to provide the information outlined below.
This information is stored securely and is used for monitoring the services we provide. By sharing
your information, it will help us to plan and monitor services, to meet your needs.
FIRST NAME: ________________________
SURNAME: ____________________
NATIONALITY: ________________________
Please answer the questions below
AGE – Which category does your age fall under? (please tick one)
16-18
19-24
25+
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 Prefer not to say
SEX - At birth, were you described as …
Female
Intersex
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Male
Prefer not to say
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GENDER IDENTITY - Which of the following describes how you think of yourself?
Female
In another way ______________
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Male
Prefer
not
to
say
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SEXUAL ORIENTATION – Which category best describes your sexual orientation?
(please tick one)
Heterosexual/straight
Gay man

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Bisexual
Other

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Gay woman/lesbian
Prefer
not
to
say


RELATIONSHIP STATUS – Which category best describes your relationship status? (please tick one)
Single

Married/Civil Partnership

Partnered/Living with partner

Separated

Divorced

Widowed/Surviving partner


Prefer not to say

Other (please specify)
RELIGION/BELIEF – Which category best describes your religion or belief?
Agnostic
Muslim

Atheist
No religion or belief

Baha’i
Pagan

Buddhist
Rastafarian

Christian (including Church of England, Catholic,
Scientologist

Protestant and all other Christian denominations)
Hindu
Shinto

Humanism
Sikh

Jain
Zoroastrian

Jewish
Prefer not to say

Other (please specify) ____________________
Created 24.06.14
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Version 3
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PRIVATE & CONFIDENTIAL
PERSONAL INFORMATION FORM
ETHNICITY – Which category best describes your ethnicity? (please tick one)
Ethnic origin categories are not about nationality, place of birth or citizenship. They are about the group
to which you as an individual perceive you belong.
A) WHITE
English/Welsh/Scottish/Northern Irish/British
Irish

Gypsy or Traveller

Any other White background (please specify)___________________

B) MIXED/MULTIPLE ETHNIC GROUPS
White and Black Caribbean
 White and Black African
 White and Asian
Any other mixed/multiple Ethnic background (please specify)___________________

C) ASIAN/ASIAN BRITISH
Indian
Pakistani


Any other Asian background (please specify) ____________________
Bangladeshi

D) BLACK/BLACK BRITISH
African

Caribbean

Other Black background (please specify) ___________________
E) OTHER ETHNIC GROUP
Chinese

Arab

Any other ethnic group (please specify) ___________________

F) Prefer not to say
LANGUAGE – What is your first language? Please tick
English
Other (please specify, including British Sign Language) _________________
Prefer not to say
Data Protection
Queen Alexandra College is registered under the Data Protection Act 1998. All the information that
you supply on this form will be processed in accordance with the regulations of the Act.
Queen Alexandra College is required to pass the information that you provide on this form to the
relevant agency funding your placement at the College. (This could include your Local Authority,
Education Funding Agency or Residential Training Unit of the Department for Work and Pensions).
These public bodies are registered under the Data Protection Act 1998. Their registration is
primarily for the collection and analysis of statistical data. They will collect and share this
information with other organisations, for the purpose of administration, careers and other guidance,
statistical and research purposes. This will allow them and their partners to monitor performance,
improve quality and plan future provision.
I hereby give permission under the Data Protection Act 1998 for Queen Alexandra College to
process the data on the Personal Information Form.
Signature of student/applicant: ________________________ Date: ___________
Please return this completed form in the prepaid envelope to: Admissions Administrator,
Queen Alexandra College, Court Oak Road, Harborne, Birmingham, B17 9TG
Created 24.06.14
Page 2 of 2
Version 3