Student ID.
(College to complete)
Enrolment Form 2016/2017
PLEASE COMPLETE ALL SECTIONS USING BLOCK CAPITALS
1. Have you been a student at Lewisham Southwark College before? Yes
No
Please enter your name as it appears on official documents:
Title: Mr
Mrs
Miss
Ms
Other
Surname /Family name
SECTION 1 - YOUR PERSONAL DETAILS
Family name/Surname
First name(s)
Date of Birth (DD/MM/YYYY)
Age on 31 August 2016 National Insurance no. ULN no. Address (please remember to let us know if you move address after applying/starting your studies)
Parental home
Own home
Other (please state)
Phone no. Email address Contact Name
Relationship Contact no.
First name
PERSON TO CONTACT IN AN EMERGENCY:
Contact Address
PRIVACY STATEMENT 2015/2016 – HOW WE USE YOUR PERSONAL INFORMATION.
Further information about use of and access to your personal data, and details of organisations with whom we regularly share data are available at:
https://www.gov.uk/government/publications/sfa-privacy-notice
Tick this box if you do not give permission for your learning information to be shared via your ULN
Please be aware that you will be contacted by Lewisham Southwark College or its representative sometime after your course has ended to ask how you have used
your new skills/qualifications.
Further details can be found at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/448849/Code_of_practice_for_sharing_personal_
information_version_3.pdfQualifications
You can opt out of contact for other purposes by ticking any of the following boxes if you do not wish to be contacted about courses or learning opportunities for
surveys for research
By post
By phone
By email
Student number
The College may ask you to participate in a photo shoot for use in College marketing materials and by signing this learning agreement you consent to and authorise
the use and reproduction of any and all photographs taken of you without compensation. If a student is under 16, we would ask for parental consent.
The personal information you provide is passed to the Chief Executive of Skills Funding (‘the Skills Funding Agency’) and the Department for Business, Innovation
and Skills (BIS). Where necessary it is also shared with the Department for Education, including the Education Funding Agency, and the UK Border Agency.
The information is used for the exercise of functions of these government departments and to meet statutory responsibilities, including under the
Apprenticeships, Skills, Children and Learning Act 2009, and to create and maintain a unique learner number (ULN) and a Personal Learning Record (PLR).
The information you provide may be shared with other organisations for education, training, employment and well-being related purposes, including for research.
You may be contacted after you have completed your programme of learning to establish whether you have entered employment or gone onto further training.
SECTION 2 - EDUCATION AND QUALIFICATIONS
Name of the school or college and the local Authority it was located in
Date you left this school (MM/YY)
Have you achieved the following qualifications?
GCSE English - grade A-C? GCSE Maths - grade A-C?
I do not have this qualification
I am awaiting results
I do not have this qualification
I am awaiting results
Please tell us about other Qualifications you already have, or are awaiting results for in the table below:
Qualification Type
A Level
AS Level
Access to HE
AVCE
Award
BTEC First
BTEC National
Certificate
Diploma
GCSE CSE/O Level CSE/O Level
GNVQ
NVQ
Other
Overseas
Qualification
Subject, Level & Grade
Date taken
SECTION 3 - ENTRY CRITERIA (For Office/Curriculum Use Only – please indicate if Entry Criteria has been met)
Level Main Qualification
Circle as
appropriate
Entry Criteria for Main Qualification/Programme
Entry Level
Applicants must show that they have the potential to successfully complete the qualification.
Yes
No
Level 1
Applicants must show that they have the potential to successfully complete the qualification.
Yes
No
Level 2
1 GCSE at Grade A* – D (including English or maths), or completion of a Level 1 programme in
a related subject.
Yes
No
Level 3
3 GCSEs at grades A* – C (including English or maths), or completion of a Level 2 programme
in a related subject.
Yes
No
Access to HE
English and Maths GCSE A* - C
Yes
No
Student meets all Entry CriteriaStudent DOES NOT meet Entry Criteria: (Manager only to Sign)
Tutor Name: Manager Name:
Tutor Signature:
Date: Manager Signature:Date:
Please indicate Current English and Maths qualification and level to be enrolled on:
Current Level
Maths
Level to Enrol on to:
English
Maths
English
Pre-Entry
Functional Skills
Entry 1
Entry 2
Entry 3
Level 1
Level 2
GCSE
Please indicate what evidence is attached: PLR
Copies of Certificate
Initial Assessment
NARIC PrintoutBy email
SECTION 4 - EQUAL OPPORTUNITIES
How would you describe your Ethnic origin? (please tick)
Asian / Asian British
White
English / Welsh / Scottish / 39
31
What is your faith/religion?
Northern Irish / British
Christian
Buddhist Indian
Hindu Muslim 40
Pakistani
Sikh Jewish
32
Irish
41
Bangladeshi
Catholic 33
Gypsy or Irish Traveller
42
Chinese
Other (please state) 34
Any Other White
43
Any other Asian
None
Gender
Background
background
Mixed / Multiple ethnic group
Black / African / Caribbean /
Male
Female
Other (please state) Black British
35
White and Black Caribbean
49
African
36
White and Black African
45
Caribbean
37
White and Asian
46
Any other Black / African /
38
Any Other Mixed / multiple Caribbean background
Sexuality
ethnic background
You have the right to keep this information confidential.
Bisexual
Gay man Gay woman/lesbian
Heterosexual Prefer not to say
Other
Other
47
98
Arab
Any other ethnic group
What is your main language spoken at home?
SECTION 5 - RESIDENCY
What is your country of birth? What is your nationality?
I was born in the UK
Have you lived in the UK/EU for the past 3 years? Yes
No (Please complete Non UK / EU Nationals questions below)
Do you have a parent who is serving in the armed forces? Yes
No
Type of ID seen:
UK Passport Number
(NON UK/EU NATIONALS ONLY)
What date did you enter the UK/EU/EEA?
Which country were you living in before arriving in the UK / EU / EEA?
What type of immigration permission do you hold in the UK?
UK/EU National
Humanitarian Protection
Refugee
Tier 4
Indefinite Leave to Enter or Remain
Discretionary Leave
Exceptional Leave
Other (please specify)
If there is a time limit on your visa permission, what date does your visa expire?
SECTION 6 - ADDITIONAL SUPPORT
The College has a wide range of additional support. (We welcome students with disabilities, learning difficulties and health problems.)
Please mark the boxes that are appropriate to you. This will enable the college to consider your additional support needs whilst on a course
with us.
Disability
Learning Difficulty
Health
No disability
No health problems
No learning difficulty
Visual impairment
Other medical condition (e.g. epilepsy,
Moderate learning difficulty
asthma, diabetes. Please state below:
Severe learning difficulty
Hearing impairment
Disability affecting mobility
Dyslexia
A disability or special need not listed (04).
Mental health difficulty
Dyscalculia
Please state below:
Temporary disability after illness
Other specific learning difficulty
(e.g. post-viral) or accident
Autistic spectrum disorder
Profound complex disabilities)
Other
Aspergers syndrome
I do not wish to give this information
Other
I do not wish to give this information
Support at interview and on course.
Please tick the following box(es)
I have a disability and may need support at interview or on my course. Yes
No
I have dyslexia and / or a learning difficulty and may need support on course.
Yes
No
IF YOU ARE AGED 14-19 PLEASE ANSWER THESE QUESTIONS
Are you living in the care of social services, leaving care services or living in any type of hostel accommodation? Yes
No
Do you receive Free School Meals
Yes
No
SECTION 7 - FINANCIAL/HOUSEHOLD INFORMATION
1) If you are working please tick one option from each column:
A: I am Self Employed
B:
C:
I work for less than 16 hours each week
I work for an Employer
I work 16-19 hours each week
current employer for less than 3 months
I am an Apprentice
I work for 20 hours or more each week
I have been working for my I have been working for my current employer for 4-6 months
I have been working for my current employer for more than 6 months
If you earn less than £330 a month and have a letter from the Job Centre to say that you still receive benefits please tick this box
2) If you are not working please tick the statement that best describes you.
I am not employed and not looking for work (tick this option if you are in full time education)
I am not employed and have been looking for work for less than 6 months
I am not employed and have been looking for work for 6-11 months
I am not employed and have been looking for work for 12-23 months
I am not employed and have been looking for work for 24-35 months
I am not employed and have been looking for work for more than 36 months
3) Are you an offender on day release to college?
Yes
No
4) Will you need to take maternity or paternity leave before the end of your course?
5) Are you claiming any of the following benefits (please provide up-to-date evidence)?
Job Seekers Allowance (Please show a recent letter from the Department for Work and Pensions - DWP)
Financial Support from Social Services as an Asylum Seeker (Please show a letter if you are 18 or under)
Employment Support Allowance (Please show a recent letter from the DWP)
Disability Living Allowance
Universal Credit
6) Are you taking this course to help you to get the skills you need to improve your chances of getting a job?
Yes
No
7) Household Situation: Please tick the statement that best describes your household:
I live in a jobless household with dependent children
I live in a jobless household without dependent children
I live in a single adult household with dependent children
None of the above
I do not wish to give this information
SECTION 8 - DECLARATION AND SIGNATURE
I hereby agree to abide by the Student Charter and Student Code and the provisions set out in the notes below:
Course advice, guidance and fees
• I confirm that I have completed a pre-entry process with Lewisham Southwark College whereby I received appropriate advice, guidance
and support to help me choose my programme of study and I understand that after assessment I may also be enrolled on appropriate Maths and English courses.
• I fully understand the entry requirements, fees, suitability and progression opportunities (where applicable)
• I understand and accept that the College reserves the right to close or combine one class with another.
• I accept that where the fee assessment process has determined I pay fees I will pay them or I will provide a formal letter of sponsorship from my
employer or other sponsoring organisation. I also acknowledge that if my sponsor does not pay promptly I will be required to settle any outstanding fees.
• I agree that if I am eligible and the College accepts me onto an instalment arrangement I will pay each instalment promptly as it falls due.
I also understand that should I withdraw from the course(s) any outstanding payments remain payable and must be paid immediately.
• I acknowledge that I have read the college’s refund policy and agree to be bound by it.
DATA PROTECTION 1998
The information you provide on this form will be passed to the Skills Funding Agency (SFA), Education Funding Agency (EFA), Home Office.
The SFA/EFA is registered under the Data Protection Act 1998. The registration is primarily for the collection and analysis of statistical data.
The SFA/EFA will collect and share this information with other organisations for the purpose of administration, careers and other guidance,
statistical and research purposes. This will enable the Council and its partners to monitor performance, improve quality and plan future
provision. If you are under 19 years some information may be passed to Connexions. All data is stored and processed in accordance with
the Data Protection Act.
• I understand that if I request a letter from the College confirming my status as a student my address may be in the letter.
• I declare that I understand the information I have entered is correct and I understand that this information will be used by
Lewisham Southwark College staff for enrolment and reporting purposes and that some information requested will be electronically stored.
Further details can be found at:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/448849/Code_of_practice_for_sharing_personal_information_version_3.pdfQualifications
For Learners who have been given a remission of fees please see below:
I have understood the basis on which I have been given:
• Free tuition under the Entry/Level 1; Level 2 or Level 3 offer. I confirm that I do not already have a full level 2, 3 or higher qualification (or the overseas equivalent).
• Remission of fees because I am in receipt of Job Seekers Allowance or Employment Support Allowance (in the Work Related Activity Group)/Universal Credits (due to unemployment)
• Remission of fees because I am in receipt of an income based benefit and I am unemployed, actively looking for work and undertaking
this course as a means to enter employment.
By signing this enrolment declaration I am confirming that the information I have provided is correct. I understand that if false information is declared, action may be taken to reclaim the course fees and any associated costs.
Attendance and Behaviour
• The College sets very high standards regarding attendance and punctuality. These standards can be viewed at www.lesoco.ac.uk/attendance
• Students must attend, on time, all planned and programmed sessions (theory and practical sessions, tutorials, English and/or Maths) within their learning programme, including assessments.
• Holidays should not be planned during term time and will count as unauthorised absences.
• Failure to meet these standards may result in you losing your place
Date:
Signature of Learner:
Staff name (print):
Staff Signature:
Main Course Details: Additional English
and Additional Maths
Qualifications:
Date:
SECTION 9 - PARENTAL/GUARDIAN CONSENT FOR STUDENTS AGED 16-18 UNDERTAKING
WORK EXPERIENCE AS PART OF THEIR STUDY PROGRAMME
I confirm that:
• I agree to the participation of my son/daughter/dependant in the visit and the activities described above;
• I accept responsibility for my son/daughter/dependant’s behaviour during the visit;
• I understand that all reasonable care will be taken by College staff to ensure the safety of those in the party;
• I accept that the insurance policy of the College does not cover personal accident or injury to members of the party of damage/loss to personal property unless it can be shown that this is due to the negligence of the College’s employee(s);
• I accept responsibility for the damage caused by my son/daughter/dependant and will pay any expenses as a result of the above,
including any cost of him/her being sent home early due to misconduct;
• I authorise the organiser, on my behalf, to arrange emergency medical treatment should it become necessary.
Parent / Guardian Name:
Please tick this box, if the student enrolled without a Parent/Guardian present:
Parent / Guardian Signature:
This activity has been directly or indirectly part-financed by the European Union through European Social
fund - helping develop employment by promoting employability, business spirit and equal opportunities, and
investing in human resources.
T: 020 3757 3000
E: [email protected]
W: www.lesoco.ac.uk