JumpStartApplication Form

Name

Email

Tel (Home) Tel (Mobile) ______

Address

______Postcode _____

Please tick to indicate how you would prefer to be contacted:

Email Post

If you are currently or have recently been studying, please specify which course(s) you have taken (e.g. GCSE English, NVQ Level 2 / 3 Supporting Teaching and Learning, Functional Skills):

______

Which college centre have you been studying at? (e.g. Burton Road, Leeds City College):

______

If you have plans for future study, please tell us what these are:

______

______

Please tick here if English is not your first language and give details of your current highest English Language qualification (e.g. ESOL Entry Level 1, English GCSE, IELTS etc):

Do you have any voluntary or unpaid work experience? If so, please tell us what this is?

______

Please tell us, in no more than 250 words, why you are interested in attending this course (please use a supplementary sheet if required)

______

Special Requirements (Mobility / Other, e.g. handouts on different coloured paper):

Criminal Convictions:

Do you have any unspent Criminal Convictions? Yes No

We would be very grateful if you would complete these details about yourself:

GENDER: Male Female Other

DATE OF BIRTH: ______

ETHNIC BACKGROUND

White Gypsy, Traveller or Irish Traveller

Black - Caribbean Black - African Black - Other

Asian - Indian Asian - Pakistani Asian - Bangladeshi

Asian - Chinese Asian - Other

White/Black Caribbean White/Black African White and Asian

Other Mixed Arab Other

Prefer not to say

WHAT IS YOUR NATIONALITY? (e.g. British, Polish, Eritrean etc.)______

DO YOU CONSIDER YOURSELF TO HAVE A DISABILITY?

Yes (please provide details) ______

No Prefer not to say

HIGHEST EDUCATIONAL QUALIFICATION:

No formal qualifications GCSE / ’O’ Level / NVQ Level 2

GCE ‘A’ Level / BTEC / NVQ Level 3

Higher Education (university) Qualification or any otherLevel 4 qualification – please describe the name of this qualification and which country you studied in:

______

Other (please specify the title and level of this qualification)______

______

Which secondary school did you attend? ______

Did either of your parents go to university? Yes No

EMPLOYMENT:

Employed full-time Employed part-time Self employed

Full-time carer for children or adults Part-time carer for children or adults

Unemployed Retired Volunteering

Other (please give details):

Please describe your most recent paid employment:

Job title / Employer / Start and end date

Where did you hear about the course?

Community organisation (please state the name of the organisation and the person who referred you if known):

______

Community event (please specify the name of the event if known):

______

Lifelong Learning Centre advert (please give details): ______

Word of mouth (please give details): ______

Internet search From a member of University of Leeds staff

Other (please specify): ______

I confirm that the information I have supplied is accurate and complete. I agree to the University processing my personal data (including sensitive data) in accordance with its Code of Practice on Data Protection and I give permission for the University of Leeds to obtain, collate, store and use my data for the following purposes: service improvement, statistics, auditing and tracking.

Signed: ______Date: ______

We would like to contact you about other events which may be of interest to you as you consider the next steps in your education. If you would prefer for us not to do so, please tick here

Please return your completed registration formto: Poppy Beacock, Lifelong Learning Centre, Marjorie and Arnold Ziff Building, University of Leeds,LS2 9JT. We will contact you to discuss your application.