Application Form

UCAP Programme (to be completed by applicant)

Have you ever applied to, or studied at Canterbury Christ Church before? (We need this information to make sure that we do not create a duplicate record for you on our computer system) / Yes No
Personal Details
Title: / Male
Female (tick box appropriately ) / Date of Birth:
Surname/Family name:
Forename:
Postal Address:
Post Code: / Home Phone Number :
(including STD/area code)
Mobile Number:
Email Address:
Department (CCCU staff) or Employer (non-CCCU staff):
Programme fee: Self-funded/sponsor/other (please supply details) (please indicate how fees will be paid)
NMC registered: Yes
No
(tick box appropriately) / Area of NMC registration:
Registration Number:
Year qualified:
Higher Education
Name of Institution: / Title: / Name of Course:
Other Relevant Professional Qualifications:
Title: / Main Subject(s): / Awarding Body: / Completion Date:
Further Personal Details
Are you a UK or EEA (European Economic Area) Citizen? / Yes (please continue with the next question - Nationality)
No (please continue with Nationality, but please also ensure youcomplete all the Passport and Visa Details Section)
Nationality. If dual, please choose one or the other
What is your country of domicile
Ethnic Origin (please circle)
We need this information for monitoring purposes only.
10 White
13 White-Scottish
14 Irish Traveller
15 Gypsy or Traveller
19 Other White Background
21 Black or Black British-Caribbean
22 Black or Black British-African
29 Other Black Background
31 Asian or Asian British – Indian
32 Asian or Asian British-Pakistani / 33 Asian or Asian British-Bangladeshi
34 Chinese
39 Other Asian Background
41 Mixed-White & Black Caribbean
42 Mixed-White & Black African
43 Mixed-White & Asian
49 Other Mixed Background
50 Arab
80 Other Ethnic Background
90 Not Known
98 Information Refused
Disability (Please circle any that apply).
We use this information to identify whether there are any support issues that the University has to consider if you become a student. The information is not used as part of the decision making process surrounding your application.
00 No known disability
02 Blind/partially sighted
03 Deaf/hearing impairment
04 Wheelchair user/mobility difficulties
05 Personal care support
06 Mental health difficulties
07 An unseen disability, e.g. diabetes, epilepsy, asthma
08 Two or more impairments and/or medical conditions
10 Autistic Spectrum disorder
11 A specific learning difficulty, e.g. dyslexia
51 A specific learning difficulty such as dyspraxia or AD(H)D / 53 A social/communication impairment such as Asperger’s syndrome/other autistic spectrum disorder
54 A long standing illness or health condition such as cancer, diabetes, chronic heart disease, or epilepsy
55 A mental health condition, such as depression, schizophrenia or anxiety disorder
56 A physical impairment or mobility issues, such as difficulty using arms or using a wheelchair or crutches
57 Deaf, or a serious hearing impairment
58 Blind or a serious visual impairment corrected by glasses
96 A disability, impairment or medical condition that is not listed above
97 Information refused
98 Information not sought
Do you receive Disabled Students’ Allowance (Please circle) / Yes
No
I am disabled, but information about the disabled students’ allowance is not yet known
Please state your faith or belief, if any.
(Please circle)
This information is not used in the decision making process for the programme you have applied for. / 01 Buddhist
02 Christian
03 Hindu
04 Jewish
05Muslim
06 Sikh
07 Any other faith or belief
08 No faith or belief
09 Faith or belief not stated
Further Information
Do any of your parents, adoptive parents or guardians have any higher education qualifications, such as a degree, diploma or certificate of higher education?
The University is asked to collect this information by the Higher Education Funding Council for England (HEFCE). The information given is not used in the selection process for your course. / 01 Yes
02 no
08 Don’t know
09 I choose not to say
Do you have any learning difficulties?
We use this information to identify whether there are any support issues that the University has to consider if you become a student. The information is not used as part of the decision making process surrounding your application. / 01 Moderate learning difficulty
02 Severe learning difficulty
10 Dyslexia
11 Dyscalculia
19 Other specific learning difficulty
90 Multiple learning difficulties
98 No learning difficulty
99 not known/information refused
Do you have any dependants? (please circle)
Yes No / If Yes, please indicate below:
01 Young people/children
02 Other relatives/friends
04 Both young people/children & other relatives/friends
Passport and Visa Details
Do you need a student visa to study here? (Please circle) / Yes
No (please move on to next section)
Country of birth
Place of birth
Passport number
Passport issue date / Day: Month: Year:
Passport expiry date / Day: Month: Year:
Passport place of issue
UK ID Card Number
Overseas HE Organisation
Visa/work permit type
(please circle) / Adult student Adult visitor
Child student Child visitor
Prospective student
Visa/work permit number
Visa/work permit expiry date / Day: Month Year:
Date of first entry to the UK (if not born here) / Day: Month: Year:
Personal Statement
Describe briefly your reasons for wanting to undertake the UCAP:
Give detail of any previous Higher Education teaching or training experience(with dates if possible):
Supporting Statement by CCCU Programme Director, Head of Department, or Equivalent Workplace Manager
  1. Please explain why you believe the applicant needs to undertake the UCAP Programme:
  1. Please indicate how the programme team will support the applicant e.g. mentor support:
  1. Please confirm that the applicant is employed on a CCCU academic/professional award:
Y/N
Office Use Only
Name of Mentor: / Mentor E-Mail:
AOS Code: PINIPACDPRT / Student I.D.:
Registered Date: / Actual Start Date:

Name……………………………………………………......

(Programme Director, HoD or equivalent)

Signature ……………………………………………………..……. Date ………..…….……

(Programme Director,HoD or equivalent)

Signature (Applicant) ………………………………………..…… Date …………………...

Please return completed form to Miranda Haston via the LTEU pigeon hole in the SCR or via email if it has been completed with electronic signatures (). For external candidates postal address is North Holmes Road, Canterbury, Kent CT1 1TU.

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