16-18 Years Application Form for Provision Name First Name Last Name Gender Parents Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone (###) ### #### Mobile Phone (###) ### #### Email What is your Nationality? Have you been living in the UK/EEA for the last 3 years? Yes No Courses you wish to apply for: 1st Choice 2nd Choice (not compulsory) Current School: EHCP Local Authority Held: Do you have any support at school for anything? Yes No Please tell us if you have any disability or learning difficulties. Please tick as appropriate: Visual impairment Disability affecting mobility Social and emotional difficulties Moderate Learning difficulty Dyslexia Autistic spectrum disorder Temporary disability after illness (e.g. post viral) or accident Other specific learning difficulty (e.g. dyspraxia, dyscalculia, ADHD) Other learning difficulty Hearing impairment Profound complex disabilities Mental health difficulty Severe learning difficulty Other physical disability Other medical condition (e.g. epilepsy, asthma, diabetes) Prefer not say None Other (please specify below) Where did you hear about the course your applying for? Keeping in touch For you to stay up to date with your application process or enquiry we will get in touch from time to time to inform you about college events including open days and other events as well as other relevant information such as new courses or services that we intend to provide. Yes please, I would like to receive communications by email Yes please, I would like to receive communications by telephone Yes please, I would like to receive communications by mobile (SMS) Yes please, I would like to receive communications by pos No, I would prefer not to be contacted Declaration Do you have an unspent criminal conviction or pending criminal investigations? Yes No If yes please give the name and the contact details of a person we can contact for further information. Date MM DD YYYY Applicant signature: Thank you for submitting Post 16 application! A member of staff will be in touch shortly.
