PERSONAL DETAILS

RESIDENCY

Office use only:

Title: Mr Mrs Miss Ms Other: Gender: M F Date of Birth: Age on 31/8/13:

Forename(s): Surname:

Home Address: Postcode:

Home tel: Mobile tel:

Email:

Next of kin name:

Next of kin contact number:

Have you been ordinarily resident in the UK or EU for the last three years? Yes No

If NO please state: Your nationality: Date of entry to UK/EU:

Do you have a legal right of abode? Yes No

Are you seeking asylum? Yes No

We want you to get the best from your time at College and can offer a range of support measures to help you successfully complete your course. Please let us know if you have any learning support needs, disabilities or medical conditions for example wheelchair user, mental health challenges,epilepsy, dyslexia, hearing or visual impairment.

Do you have a learning difficulty, disability or health need which may affect your ability to study? Yes NoIf YES please state

Did you receive additional support in school or in your previous college? Yes NoIf YES please state

Do you have a section 139a learning difficulty assessment? Yes No

If you tick any of the above you will be contacted by a member of staff to discuss your support needs.

Do you give permission for this information to be shared with other relevant staff within PRC? Yes No

APPLICATION FORMFOR FULL-TIME STUDENTSSTARTING FROM SEPTEMBER 2013

Please complete in BLOCK CAPITALS in BLACK INK. Please complete all sections of this form in full.Any missing information may lead to delays in processing your application. To return this form justpop it in an envelope (NO STAMP REQUIRED) and send it to: Full-time Applications, PeterboroughRegional College, FREEPOST PE259, Park Crescent, Peterborough, PE1 4BR.

ADDITIONAL SUPPORT

Are you in the care of the local authority? Yes No

We need to ask all applicants whether they have any criminal convictions. Do you have any unspent criminal convictions? Yes NoIf you answer ‘yes’, you will not automatically be excluded from the application process, however, we may ask you for more information.Please note that attendance on some programmes or essential work placements may be subject to a successful Criminal Records Bureau check. If you fail to declare a criminal conviction this may end any applicationor enrolment at Peterborough Regional College. If you are unsure if your conviction is relevant, please seek advice from NACRO, your probation service, the Citizens Advice Bureau or the College Information Centre.

Please list the programme name and code you wish to study below (as they appear in the course guide):

Title Code

1st Choice

2nd Choice

PROGRAMME YOU’RE APPLYING FOR:

EQUAL OPPORTUNITIES

Please help us to monitor our equal opportunities policy by completing this section. This data will only be used for statistical analysis.I consider my ethnic origin to be:

English / Welsh / Scottish /Northern Irish / British

Irish

Gypsy or Irish Traveller

Any other White background

White and Black Caribbean

White and Black African

White and Asian

Any other Mixed / multipleethnic background

Indian

Pakistani

Bangladeshi

Chinese

Any other Asian background

African

Caribbean

Any other Black / African/Caribbean background

Arab

Any other ethnic groupplease specify:

33

32

35

34

31

36

37

38

39

40

41

42

43

44

45

46

47

98

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Qualifications achieved Date achieved Grade Qualifications currently studying Completion date Estimated grade

QUALIFICATIONSPlease list any qualifications you have and your grades: Please list any qualifications for which you are studying and predicted grades:

WORK EXPERIENCEIf you have any work experience (paid or unpaid) please let us know about it: (where did you work, what did you do, etc.)

REASONS FOR APPLICATION / CAREER PLANPlease give reasons why you are applying for this course/ or what are you future career goals.

SIGNATURE OF APPLICANT Date: / /

DECLARATIONI understand that the information provided on this form may be used for any matter relating to my application and for statistical and research purposes bythe College or organisations commissioned by the College. Information provided on ethnic origin is for statistical purposes only and will be treated as strictlyconfidential. The Funding Authority/Peterborough Regional College may wish to contact you in the future. If you do not wish to be contacted please tick theappropriate boxes. I do not wish to be contacted by the Funding Authority I do not wish to be contacted for market research purposes I do not wantto be contact by the College/Funding Authority in relation to courses, events or other services

ADDITIONAL INFORMATIONPlease tick if you are aware of any of the following sources of advertising by the College:

Newspaper Radio Event Poster/banner Other source

Evening Telegraph Stamford Mercury Heart FM Queensgate Town AA Signs E-mail/text

Hunts Post Cambs Times Connect FM School Visit School Mail shot/e-mail Connexions

Other Kiss FM Other Library Website Other

Other Other Bus advert Yellow Pages/Phone Book

N3

N4

N5

N9

R1

R2

R3

R9

E1

E3

E9

P1

P2

P3

P9

A

M

W

B

X

Z

Y

C

N1

You will need to provide a reference or school report at interview.

EDUCATION (If you are 16-19)Most recent school / college:

Name of tutor / class:

Please tick here if you are a current full-time student at PRC:

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