Section 1. Course Details (Please use CAPITAL LETTERS)
I want to study:
I want to start in:
I want to study:
Section 2. Personal Details
Date of birth:
DD / MM / YY
Previous last name (if changed):
National Insurance no:
Car registration no:
Unique learner no.
Last school/college attended:
Usual permanent address (if different):
Emergency contact details:
Tel (Mobile): Tel (Work):
If you are under 19, please supply parent/guardian email:
Section 3. Nationality
Where were you born?
Where do you live now?
How long have you lived in the EU?
If you’ve lived here for less than 3 years please tell us your date of entry into the EU/UK: DD / MM / YY
Please tick if any of the following apply to you:
Indefinite leave to remain
Limited leave to remain State expiry date: DD / MM / YY
Please supply supporting evidence including passport.
Do you have any unspent convictions or pending court cases?
The student has been assessed on entry to their Learning Programme as requiring additional support: Yes / No
Level on Entry: 1 2 3 4 5 6 Date application received: Date enrolled:
Section 4. Support Services
In order that Guildford College can provide appropriate support for you, please tell us about any particular health, educational or domestic issues you may have. Any medical information you provide will be shared with the appropriate people in the case of an emergency situation. Please tick all that apply and give further details on a separate sheet if necessary:
01 Blind/visual impairment
02 Deaf/hearing impairment
03 Mobility difficulties
04 Other physical difficulties
06 Emotional/behavioural difficulties
07 Mental health issues
90 Multiple disabilities
98 No disability
Do you have a medical condition which significantly affects daily life? Please give details on a separate sheet:
I have to carry routine/prescribed medicines
I am receiving medical treatment by my GP/hospital
I have an EpiPen for anaphylactic shock recovery
I have been given medical advice to follow in an emergency
Have you any other learning or health conditions you would like to discuss?
01 Moderate learning difficulty
02 Severe learning difficulty
19 Other specific learning difficulty
20 Autism spectrum disorder
90 Multiple learning difficulties
98 No learning difficulty
Have you had learning support before?
Have you had special arrangements for exams before?
Section 5. Ethnicity
Monitoring of ethnic origin. Completion is voluntary and information supplied will be used only for statistical purposes and will be treated as confidential. Please tick the group to which you belong:
31 White - British
32 White - Irish
34 White - any other
33 Gypsy or
41 Asian or Asian
39 Asian or Asian
British - Indian
40 Asian or Asian
British - Pakistani
43 Asian or Asian British - any other Asian background 44 Black or Black
British - African
45 Black or Black British
46 Black or Black British - any other Black background 47 Arab
37 Mixed - White and Asian
36 Mixed - White and Black African
35 Mixed - White and Black Caribbean
38 Mixed - any other
98 If none of the above, please specify details:
Section 6. Reference and Employment
If you are currently in full-time