10455 CLL Guide 2010:Vis 1 28/06/2010 10:26 Page 29
Enrolment Form
Prior Pursglove College Community Learning & Leisure Guide 2010-2011
Please note we require your national insurance details on the enrolment form. Please make sure that you complete both sides of the form using block capitals or as appropriate. Personal Details Surname:
Dr/Mr/Mrs/Miss/Ms/other:
Forename(s):
Date of Birth:
Address: Postcode:
National Insurance Number:
Tel. No. Home/Mobile:
Work:
Emergency Contact Name:
Tel. No.:
Residency Status Have you lived in the United Kingdom for the last 3 years?
Yes
No
If the answer is No, you must attach evidence of your residency status so that we can establish whether you are a ‘home’ or ‘overseas’ student for fee purposes.
Employment Status Full time education
Unemployed for less than 6 months
Employed
Unemployed between 6 and 11 months
Self-employed
Unemployed between 12 and 23 months
Retired
Unemployed between 24 and 35 months Unemployed for 36 months or longer
Course(s) applied for Course Code
Subject
Day
Time
£*
PY
:
PY
:
PY
:
* Please enter FR if you are claiming fee remission.
Sub Total Registration Fee Total Due
: £5:00
:
For Office Use Only £5 registration fee enclosed Tuition Fees enclosed Invoiced
Yes / No Yes / No Invoice No: Received: Evidence of fee remission seen Yes / No / NA State type of evidence seen Evidence of employer support Attached Yes/No Employer invoiced Invoice No: Received: Entered on CIS Personal details Fee type
: £ Cash / Cheque : £ Cash / Cheque : £ : £ Cash / Cheque Staff Signature:
£ : : £ Cash / Cheque Course details SLDD
Receipt No: PY Receipt No: PY Receipt No: PY
Receipt No: PY
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10455 CLL Guide 2010:Vis 1 28/06/2010 10:26 Page 30
Attach two photos
Fees • I will be paying the fees myself • My employer will be paying (Please attach a letter from your employer on headed paper confirming this)
• I am entitled to fee remission (Please the reason below and attach proof, eg benefit letter or award notice, so we can determine if you are eligible or not) a) Aged 16-18 on 31st August 2010 b) In receipt of one or more of the following benefits: Council Tax Benefit
Job Seekers Allowance
Housing Benefit
Pensions Guarantee Credit
Income Support
Working Tax Credit
c) The unwaged dependant of someone in receipt of one of the above benefits. (Please also one of the boxes above to indicate which benefit/s) d) Taking a programme where the learning aim is basic skills. e) An asylum seeker in receipt of the equivalent of a means tested benefit.
Ethnic Origin White:
Irish
other White
White & Black Caribbean
White & Black African
White & Asian
other mixed
Indian
Pakistani
Bangladeshi
other Asian
Black or Black British: Black Caribbean
Black African
other Black
Chinese or other ethnic group: Chinese
other ethnic group
Mixed:
British
Asian or Asian British:
Additional Support If you consider yourself to have a learning difficulty and/or disability, it would be helpful to us if you could let us know so that we can support you on your course. Please complete the following: I consider myself to have a learning difficulty and/or disability
Yes
No
If Yes, please give details below or, if you prefer to, please contact the College and speak with a member of the Community Learning and Leisure Team.
Previous Achievements and Qualifications I currently hold the following qualifications (please tick): Below Level 1
Full Level 3 (equivalent to two A Levels)
Level 1
Level 4 or above
Full Level 2 (equivalent to five GCSEs, grades A – C)
Data Protection and Consent to Process Information The College has to collect information about all of its students for various administrative, academic and health and safety reasons including returns to the funding bodies. Under the terms of the Data Protection Act 1998 we need your consent to do this. Since we cannot operate the College effectively without processing information about you, we need you to sign the following Consent to Process Statement. If you require any further information about this please contact the Director of Administration. Consent to Process Information: I agree to Prior Pursglove College processing personal data contained on this form, or other data which the College may obtain from me or other people, whilst I am a student. I agree to the processing of such data connected with my studies or my health and safety whilst on the premises, or for any other legitimate reason.
Signed:
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Date: