| Student Name: |
|
| Course Applying for: |
|
| |
|
| SECTION 1 - PERSONAL DETAILS |
|
| Surname: |
|
| Forenames(s): |
|
| Date of Birth: |
|
| Gender: |
|
| Email: |
|
| Address 1: |
|
| Address 2: |
|
| Address 3: |
|
| Address 4: |
|
| Postcode: |
|
| Home Telephone Number: |
|
| Emergency Contact 1 Name: |
|
| Emergency Contact 1 Number: |
|
| Emergency Contact 1 Relationship to Student: |
|
| Emergency Contact 2 Name: |
|
| Emergency Contact 2 Number: |
|
| Emergency Contact 2 Relationship to Student: |
|
| If you have passed either of the following GCSE exams, please let us know the grade you achieved: |
Maths
English
|
| |
|
| SECTION 2 - INTERESTS |
|
| Why would you like to do this course? |
|
| What are your career ideas at the moment? |
|
| What do you hope to achieve? |
|
| Have you discussed your career options with a Connexions adviser? |
|
| What things are you good at? |
|
| Which skills will help you in your chosen course? |
|
| |
|
| SECTION 3 - INDIVIDUAL NEEDS |
|
Do you have a medical condition, learning difficulty or disability that may affect your studies?
If so, what do you require extra help with? (please tick) |
Writing
Study Skills
Spelling
Numeracy
Medical Conditions
Other Specific Learning Difficulties |
| Are there any religious considerations we need to know of? If yes, please give brief details. |
|
Is there is anything else you would like to make us aware of?: |
|
| |
|
| SECTION 4 MEDICAL INFORMATION |
|
| Please tick the appropriate boxes if you suffer from any of the following: |
Asthma
Fits, fainting/blackouts
Allergies (give details)
Travel sickness
Bronchitis
Diabetes
Heart condition
Severe headaches
Other (give details)
Further Details:
|
| Have you received vaccination against Tetanus in the last ten years? |
|
| Are you presently receiving medical treatment of any kind from your family doctor or hospital? |
If yes, please give brief details:
|
| Have you during the past three months been given any specific medical advice to follow in emergencies (eg epipen, inhaler etc)? |
If yes, please give further details:
|
| If any of these apply please give information on medication used including the type and dosage. |
|
| |
| If there are any other problems medical or otherwise not listed here, please give details below.
It is important that the staff know about any illness, allergies, conditions or medication which your child may have and which may affect his or her participation. Medical information will be treated in confidence. |
| |
| FOR UNDER 18’s
I consent to
(name) receiving emergency medical treatment if necessary: I understand that the providers will do their best to contact me prior to any such treatment. |
| |
|
| Any Further information. |
|
| |
|
