Please Complete All Parts of This Form in CLEAR BLOCK CAPITALS and Black Ink. Completed

RETFORD POST–16
CENTRE /

A P P L I C A T I O N F O R M

Please complete all parts of this form in CLEAR BLOCK CAPITALS and black ink. Completed forms should be returned to Kim Burgess, Retford Post-16 Centre, Old Hall Drive, Retford. DN22 7EA.

Telephone: 01777 861400

Family Name / First name
Date of Birth / Male / Female
Permanent Home Address
Post Code
Mobile Telephone Number / Evening Telephone Number
Have you lived in the UK or other European Union Country for the whole of the last 3 years? / Yes / No
Which course are you applying for?
A Levels / Other
Possible subject choice / Please specify

The Retford Post-16 Centre is a partnership of The Elizabethan High School, Retford Oaks High School, St Giles School and North Notts College, working in close collaboration with the Worksop Post-16 Centre, Tuxford School, Portland School, Valley School and Serlby Park School

Why are you interested in this course? Please give any further information that may support your application including leisure interests and career aim
Please give the name and address of the last school you attended (or are attending)
Post Code
Actual or expected leaving date
Do you have a Record Achievement / Progress File / Yes / No
Do you have a Connexions Action Plan? / Yes / No
Qualifications already achieved (eg GCSE, GNVQ etc)
AWARDING BODY / EXAMINATION SUBJECT / LEVEL / YEAR / GRADE
Examinations to be taken
AWARDING BODY / EXAMINATION SUBJECT / LEVEL / DATE TO BE TAKEN / EXPECTED GRADE
The Centre is committed to ensuring that ALL students realise their potential. Are there any barriers to your learning that we need to remove? Please help us by ticking any of the boxes below
Deaf or hearing impairment / Reading/writing difficulties / Dyslexia, dyscalculia
Visual impairment / Other learning or physical disability – please specify below
Do you require any special arrangements for your interview? If yes please specify below. / Yes / No
Do you have any medical condition that may affect your choices? / Yes / No
How did you hear about the Centre? Please tick all of the boxes that apply.
Friend/Relative / Connexions / Launch Event
Post-16 Options Evening / Employer / Centre Leaflet/Prospectus
Through School / Newspaper Advert or Article / Radio
Your ethnic origin
Asian or Asian British / Mixed / White / Black or Black British / Other
Bangladeshi / White/Asian / British / African / Chinese
Pakistani / White/Black Caribbean / Irish / Caribbean / Any other
Indian / White/Black African / Other / Other
Other mixed
I declare the information given in this form is correct. The information on this form is covered by the Data Protection Act and may be used for statistical purposes. It will not be passed onto any third parties, although information will be passed to other departments in the centre.
Signed / Date
Signature of Parent/Carer (if under 18 on 1st September of the year the course begins).
Signed / Date
Name (please print)
Address (if different from that given above)
FOR OFFICE USE ONLY
Date Application Received
Interview Date / Interviewer
Comments