Suffolk One Student Application

Personal Student Information

Title *

Mr

Miss

Mrs

Ms

Other

First Name (on birth certificate) *

Preferred First Name (if different from that on birth certificate)

Surname (on birth certificate) *

Gender *

Male

Female

Date of Birth (DD/MM/YYYY) *

Home Address *

Line 1 *

Line 2

Town *

County *

Postcode *

Student Home Phone Number *

Student Mobile Phone Number

Student E-mail Address *

Parent/Carer Information

Title *

Mr

Miss

Mrs

Ms

Other

First Name *

Surname *

Relationship to Student *

Home Phone Number *

Mobile Phone Number

E-mail Address *

Courses Applied For

For A-Levels you must select at least four subject choices

Choice 1 * Choice 2 Choice 3 Choice 4 Choice 5

Education

Current School or College *

From (DD/MM/YYYY) *

To (DD/MM/YYYY) *

Please complete the following table for any examinations/qualifications. Please give grades where possible.

The following table MUST be completed in full in order to progress your application.

Subject	Award (e.g. GCSE, BTEC)	Year taken	Predicted Result	Actual Result

Ethnic/Cultural Details

Ethnicity? *

If other please state

Home Language? *

If other please state

First Language? *

If other please state

Further details will be required in the Additional Support section

Nationality *

If other please state

Religion? *

If other please state

Have you been a resident in the UK for the last 3 years? *

Yes

No

Additional Information

Why have you chosen these courses - What is your intended career path?

Please list all your hobbies and interests (including membership of clubs and societies etc.)

Additional Support

Have you been assessed as having a learning difficulty? - Please bring a copy of the report with you to your interview. *

Yes

No

Have you had a Statement of Special Educational Needs or been supported on School Action Plus or School Action? - Please bring a copy of the report with you to your interview. *

Yes

No

Did you have special arrangements in your GCSE exams? *

Yes

No

Please state which arrangement e.g. extra time, reader etc.

Do you have an Autistic Spectrum Disorder? E.g. Asperger Syndrome. - Please give details and bring a copy of the report with you to your interview. *

Yes

No

Please give details.

Do you have any problems with eyesight (other than glasses) severe enough to affect your learning? *

Yes

No

Do you have problems with hearing, serious enough to affect your learning? *

Yes

No

Current support/adjustments: e.g. seating arrangements, hearing aids

Do you have a mental health difficulty, e.g. panic attacks, OCD, depression? *

Yes

No

Please give details.

Do you have a physical or medical condition? E.g. mobility difficulties, epilepsy, diabetes, ME, add/adhd? *

Yes

No

Please give details.

Do you use a wheelchair? *

Yes

No

Are you colour blind? Occasionally this needs to be considered in subjects such as geography or chemistry. *

Yes

No

Would you like a Study Plus class? (An additional support class) *

Yes

No

ESOL: if English is NOT your first language, then please state:

Your first language

When did you arrive in the UK, or how long have you lived here?

Do you wish to use a bi-lingual dictionary in exams? *

Yes

No

Do you have any other health problems? *

Yes

No

If yes, please give details.

Are you currently in care, or have you recently left care? *

Yes

No

Any other needs or additional information

Referee

A reference will be automatically requested from your Head of Year at your current school. Please ONLY give details of a different referee if your individual circumstances demand this e.g you have a home tutor

Name

Position

E-mail Address

Declaration

I confirm to the best to my knowledge that the information on this form is correct & complete. If accepted as a student I agree to abide by the Centre Regulations.

Please indicate that you give permission for your previous student information to be passed from the Local Authority to SUFFOLK ONE. This will provide the right support for you while completing your course.

DATA PROTECTION - the information you have provided will be stored on computer and used to process your application. The information may be disclosed to the Careers Service, Local Education Authority, Awarding Bodies, Funding Councils, the Higher Education Statistical Agency and if you are under 18 years of age, to your parents/guardian.

I accept