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
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