HALESOWEN COLLEGE Please complete this form clearly and accurately using BLOCK CAPITALS OR if you prefer apply online at www.halesowen.ac.uk

RETURN TO: Admissions, HALESOWEN COLLEGE Whittingham Road, Halesowen, West Midlands B63 3NA

Student ID No.(for office use only)

PART 1: IMPORTANT INFORMATION ABOUT YOU AND YOUR COURSELast name First name Date of Birth

Address

Postal Code

Phone - Home Mobile Email address

Are you already attending Halesowen College? Yes No

Name and brief address of Schools/Colleges last attended Leaving Date(Please indicate all Schools/Colleges attended since Year 7, including any attended after Year 11)

If you are not a Year 11 student have you taken any qualifications since leaving school? Yes No

Course Grade

Note - Information will be used to process your course enrolment and will be held and processed in accordance with the College’s Data Protection Policy.We may contact you from time to time regarding future College events and new courses. If you would prefer not to be contacted please tick this box

Course Grade

APPLICATION FORMAdmission 2018-2019

Box 3 - Work Based Learning (Learning Apprenticeships)

Box 2 - Vocational courseBox 1 - A Level Subjects - please give subjects

COURSE APPLIED FOR AT HALESOWEN COLLEGE - Please complete 1 box OR

(see page 89-98) Yes OR

Do you wish to be considered for Enhanced A Level Pathways Yes No Subject

please tick appropriate box

Subjects to be taken in Year 11 (or already achieved) Level Subjects already taken Year ResultsList all subjects (H/I/F) before Year 11 Taken (if known)

PERSONAL STATEMENT:Tell us about yourself and why you have applied for this option (attach a separate sheet, if you wish)

Do you have a learning difficulty? Yes No

SUPPORT NEEDS - (including disabilities or learning difficulties) IMPORTANT: ALL applicants should complete this sectionDo you have any support at school to assist you in your learning? Yes No If YES give details

Do you receive any special arrangements for taking examinations, eg extra time, Scribe or Reader Yes No

WE WOULD LIKE TO GIVE YOU THE SUPPORT YOU NEED TO ATTEND OUR CLASSES. Please tick any of the boxes below, if they describe you

Information of this nature will be passed to the Learning Support Manager who will contact you to discuss your support needs

PERSONAL AND EQUAL OPPORTUNITIES INFORMATION:

Gender: Male FemaleNationality

How long have you lived at your current address?If less than 3 years - previous address:

Have you been resident in the UK or a European Union country for at least the last 3 years? Yes No

If No, please complete this section and enclose any supporting documents state date of entry to UK and where you have been resident:Are you and your family seeking asylum in the UK? Yes NoWhat was your date of entry to the UK?Do you have the Right of Abode or Indefinite Leave to enter and remain in the UK Yes No

PART 2: INFORMATION WE NEED FOR OUR RECORDS

What is your ethnic group? Choose the option that best describes your ethnic group or background

English/Welsh/Scottish/Northern Irish/British (31)Irish (32)Gypsy or Irish Traveller (33)Any Other White Background (34)White and Black Caribbean (35)White and Black African (36)White and Asian (37)Any other mixed/Multiple Ethnic background (38)Indian (39)

Pakistani (40)Bangladeshi (41)Chinese (42)Any other Asian background (43)African (44)Caribbean (45)Any other Black/African/Caribbean background (46)Arab (47)Any other ethnic group (98)

ETHNICITY

Are you in receipt of Free School Meals? Yes No

Have you applied to any other College or 6th Form? Yes NoIf YES please specify

I confirm that I have read and understood the statement about personal and sensitive data in the College Prospectus and am happy to comply with this as part of my applicationApplicant’s Signature Date

Signature of Parent or Guardian (if under 18) DateAs soon as we receive your application, your school/college will be contacted for a reference, predicted grades and support required to assist your learning (if appropriate).

Have you had any Careers Advice? Yes NoHave you attended an Open Day at Halesowen College? Yes No

PART 3: DATA PROTECTION ACT 1998 AND SIGNATURES

Are you currently in care? Yes No

Do you have a Disability/Health/Medical Condition? Yes No

Asperger’s Syndrome (10)Moderate learning difficulties (01)Severe learning difficulties (02)Dyslexia (11) Multiple Disabilities (90)Other specific learning difficulties (19)Autism spectrum disorder (20)Multiple learning difficulties (90)Other (97)

Visual impairment i.e. difficulty seeing (01)Hearing Impairment i.e. difficulty hearing (02)Disability affecting mobility i.e. difficulty moving (03)Other physical disability (04)Other medical conditions e.g. epilepsy, asthma, diabetes (05)Emotional/behavioural difficulties (06) Mental iIl health (07) Temporary disability i.e. broken leg or arm (08)Profound or complex disability (9)

If YES please tick the appropriate box(es) below: If YES please tick the appropriate box(es) below: