City and Islington College
Reference Form 2013/14

Please complete all the fields below. NB: We are unable to process any applications without a reference from the applicant’s school or college. Please email completed references to

Section One:

*First Name of Applicant: *Surname of Applicant:

*School/College: *Date of Birth:

*This information is essential, as it will be used to match the reference to the correct the applicant

Section Two

Does the applicant have: an SEN Statement? Moving On Plan / S139A Statement CAF/E-CAF

Is the applicant in receipt of Free School meals? Yes No

Home situation: Living with a parent guardian or family member In care Just left care

Living in a hostel or homeless Alone in this countr y Looked After Child (LAC)

Not living with a parent guardian or family member

Support needs (Tick box and comment if appropriate)

English Language Pastoral Medical Learning

Was the applicant receiving additional or targeted suppor t from your staff or other agencies? Yes No

If yes please give details and tell us what suppor t they will need (including help with exams):

Section Three

Recommended course level for the applicant (this should follow from the predicted grades in section 4)

Entry Level Level 1 Level 2 Level 3 Level 4 and above

Punctuality (Please provide actual numbers ) Number of days late out of

Attendance (please tick one only) Good Fair Poor

Deadlines (please tick one only) Good Fair Poor

Working with others (please tick one only) Good Fair Poor

Working independently (please tick one only) Good Fair Poor

Behaviour and Discipline (please tick one only) Good Fair Poor

If you have indicated ‘Poor’ for any of the above, please provide details in the space below:

Section Four

Please use the space below to tell us about the applicant e.g. strengths, achievements and where they need to improve:

Section Five

Please can you enter the predicted grades of the student

Subject / Predicted Grade / Actual Grade

Full Name Position

Signature Date

PLEASE EMAIL THIS FORM TO:

Telephone enquiries: 020 7700 9200

Or post to: Course Information Unit,

City and Islington College,

PO Box 19025,

London,

N7 OWQ