/ Sixth Form Application Form for September 2017
This form must be returned by31 January 2017 to:
Year 12 Admissions, Elutec, Yew Tree Avenue, Rainham Road South,
Dagenham East, RM10 7FN or
ABOUT YOU
First Name: / Middle Name: / Gender:
Last Name: / Date of Birth: (dd/mm/yyyy)
1.Main home address / 2.Additional home address (if applicable)
Line 1: / Line 1:
Line 2: / Line 2:
Town: / Town:
Postcode: / Postcode:
Contact details
Mobile: / Home telephone:
Email:
EDUCATION DETAILS
Current / last secondary school or college:
EDUCATION DETAILS
Present courses being studied/qualifications achieved
Subject / Qualification / Grade (predicted or actual)
Subject / Qualification / Grade
MORE ABOUT YOU
Please tick the appropriate box to indicate which pathway you think you will take
 / Level 2 – if you are not expecting many GCSEs at C or above
 / Level 3 – if you are expecting C or above in most of your GCSEs
If you have chosen level 3, please indicate which courses you would like to take. You can choose up to 4 (engineering counts as 2 choices)
Engineering diploma / Physics A level / Computer scienceA level
Maths A level / Chemistry A level / BTEC Nationals in IT
Further maths A level / Biology A level / BusinessA level
English A level / BTECApplied science / Product design A level
Are there any additional subjects you would like to study? If yes, please state
ADDITIONAL INFORMATION
Special Educational Needs

Do you have a Statement of Special Educational Need or an Education, Health and Care Plan?

Yes / No

If yes, please provide details

Do you consider yourself to require support?

Yes / No

If yes, please provide details

HOW DID YOU HEAR ABOUT US
 / Word of mouth /  / Careers event /  / Newspaper /  / Careers Services
 / From your current school /  / Website /  / Facebook /  / Rear of the bus
 / Other, please state
Why do you want to study at Elutec sixth form?
PARENT/CARER DETAILS
Main contact / Address(as per page 1) / 1 / 2
Title: (Mr/Mrs/Miss) / First name:
Relationship to student: / Last name:
Email:
Home telephone: / Mobile:
DATA PROTECTION

Elutec will use this application form to collect information about the applicant for various administrative academic and health and safety reasons. The Data Protection Act 1988 requires applicant to sign the following ‘consent to proceed’ clause.

I agree to Elutec processing personal data, including data about my ethnicity and physical or mental health, obtained in this form, or any other data, which Elutec may obtain from me or other people. I agree to the processing of such data for any purposes connected with my application or my health and safety, or any other legitimate reason.

If you are under the age of 18 at the time you apply to a course, Elutecwill normally share information about all aspects of your application with your parents/carers.

Signature of student: / Date:
Signature of parent/carer
(if applicant is under 18): / Date:
Elutec Sixth Form Application Form / Page 1 of 4