Enrolment Form Personal Details
Please complete using BLOCK CAPITALS Learner Code:
Title (Mr, Mrs, Miss, Ms, Other) / Gender:
First Name:
Surname: / Post Code:
Date of Birth: (DD/MM/YY)
Address:
County:
Contact Details
Telephone Number (Home): / (Mobile):
Email Address:
Emergency Contact name & number:
Health
Do you consider yourself to have a learning difficulty and/or disability and/or health problem? You have the right NOT to disclose your disability (including learning difficulties) but this may mean we will not be able to provide you with relevant support.
Please circle your primary/main difficulty or disability
Yes / ☐ / No / ☐
Asperger’s syndrome / ☐ / Other physical disability / ☐
Autism spectrum disorder / ☐ / Other specific learning difficulty / ☐
Disability affecting mobility / ☐ / Prefer not to say / ☐
Dyscalculia / ☐ / Profound complex disabilities / ☐
Dyslexia / ☐ / Severe learning difficulty / ☐
Hearing impairment / ☐ / Social & emotional difficulties / ☐
Mental health difficulty / ☐ / Temporary disability after illness or accident / ☐
Moderate learning difficulty / ☐ / Speech, Language and Communication Needs / ☐
Other disability / ☐ / Visual Impairment / ☐
Other learning difficulty / ☐
Other medical condition ( Epilepsy, Asthma, Diabetes) / ☐
Additional Learning Support
If you think you may need Additional Learning Support or special arrangements with your learning?
Would you like us to contact you to discuss your needs / Yes / ☐ / No / ☐
Would you like us to inform your tutor of your needs / Yes / ☐ / No / ☐
Employment Status on First day of Learning
Self Employed 19+ Hours (FT) / ☐ / Employed 19+ Hours (FT) / ☐
Self Employed 16-19 Hours (PT) / ☐ / Employed 16-19 hours (PT) / ☐
Self Employed 15 Hours or less (PT) / ☐ / Employed 15 hours or less (PT) / ☐
If not employed are you:
Not in paid employment and looking for work / ☐ / Not in paid employment and not looking for work/Retired / ☐
And please tick whether you have been
Unemployed/Retired less than 6 month / ☐ / Unemployed/Retired for 24-35 months / ☐
Unemployed/Retired for 6-11 months / ☐ / Unemployed/Retired for over 36 months / ☐
Unemployed/Retired for 12-23 months / ☐
Unemployed but working less than 16hrs per week with a wage of less than £330 per month / YES/NO / If Yes: how long have you been unemployed?
…………Years………………Months
If you are in receipt of JSA/ESA (I confirm that)
I am in receipt of JSA / Yes / ☐
I am in receipt of ESA (WRAG) / Yes / ☐
If you are in receipt of any state benefit (I confirm that)
National Insurance Number (Mandatory) / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
I am in receipt of another state benefit (not JSA/ESA)
(If working tax credit household income of less than £16,010) / Yes / ☐
What is the main benefit you are receiving?
I am 19-23 and this is my First Full Level 2 Qualification / Yes / ☐
I am 19-23 and this is my First Full Level 3 Qualification / Yes / ☐
I am in receipt of a state benefit other than JSA/ESA, earn less than £300 per month and the course I am enrolling on is directly relevant to my employment prospects and the local labour market needs / Yes / ☐
I agree to inform Adult Community Learning if I stop receiving my benefit in order to start work. I understand that if I have declared false information, action may be taken to reclaim tuition fees and any associated costs from me.
Household Situation
Please tick which of the following statements apply (one or more may apply)
No household member is employed and the household includes one or more dependants / ☐
No household member is in employment and the household does not include any dependants / ☐
I live in a single adult household with dependent children / ☐
Withholding information / ☐
None of the above applies. / ☐
Residency Status
Were you born in the UK? / Yes☐ / No☐
If “No” have you lived in the UK or EU country for the last 3 years / Yes☐ / No☐
If “No” what is your immigration status?
Please note: learners who have not been resident of the UK, EU or the EEA for 3 years prior to the beginning of their course will be charged at the unsubsidised rate, please ask for details.
Ethnicity
White
English/Welsh/Scottish/Northern Irish/British / ☐ / Any other White background / ☐
Gypsy or Irish Traveller / ☐ / Irish / ☐
Mixed/Multiple ethnic group
White & Black Caribbean / ☐ / White & Black African / ☐
White & Asian / ☐ / Any other Mixed/multiple ethnic background / ☐
Asian/Asian British
Indian / ☐ / Pakistani / ☐
Bangladeshi / ☐ / Chinese / ☐
Any other Asian background / ☐
Black/African/Caribbean/Black British
African / ☐ / Caribbean / ☐
Any other Black/African/Caribbean background / ☐
Other
Arab / ☐ / Any other group / ☐
Prefer not to say / ☐
Qualifications (Please tick highest level achieved)
Entry Level / ☐ / Level 4 (HNC, CertHE, Higher Apprenticeship Level) / ☐
Other Qualifications below level1 / ☐ / Level 5 (HND, DipHE, Foundation Degree Level) / ☐
Level 1(GCSE D-G) / ☐ / Level 6 (BA Hons, BSc Hons, Degree without honours Level) / ☐
Full Level 2 / ☐ / Level 7 and above (MA, MSc, MEng, PGCE, PhD Level) / ☐
Full Level 3 / ☐ / No Qualifications / ☐
GCSE Maths A*-C / ☐ / Below A*-C / ☐
GCSE English A*-C / ☐ / Below A*-C / ☐
Enter Details of The Course/s You Wish to Study Below
Course Code / Course Title / Fee £
Have you studied these course/qualifications before / Yes☐ / No☐
If yes – Please provide name and address of learning provider
To be completed by a member of Adult Community Learning staff (at time of enrolment)
Funding Aim: / Learner Code:
Planned end date: / Planned Learning Hours:
SOF:105 / FM:35/99 / FFI:FF/CF/NF / Delivery Post Code:
Where did you hear about us
ACL Event / ☐ / ACL Brochure / ☐
ACL Website / ☐ / Poster/Flyer / ☐
Bus Shelter / ☐ / Press Advert / ☐
Course Listings / ☐ / Radio Advert / ☐
Email Newsletter / ☐ / Social Media / ☐
Existing Learner / ☐ / Text Message / ☐
Floodlight/Hotcourses / ☐ / Train Advert / ☐
Internet Search / ☐ / Word of Mouth / ☐
ACL Privacy Statement
Adult Community Learning (ACL) on behalf of Essex County Council (ECC) is collecting your personal information in order to register you on a course and to be able to inform you of any changes to the course. This information will be shared with the Skills Funding Agency/Education Funding Agency as per the statement below, as well as the learner record service in order to obtain a Unique Learner Number; Ofsted may request learner information during an inspection. This information may also be shared with a student financial support company for the purpose of processing payments. We will also share your contact information with an ACL contracted company who may contact you for education and employment related outcomes.
Funding Agencies Privacy Statement 2016/17, How we use your personal information
The personal information you provide is passed to the Skills Funding Agency, and the Department for Business, Innovation and Skills. Where necessary it is also shared with the Department for Education, including the Education Funding Agency. The information is used for the exercise of functions of these government departments and to meet statutory responsibilities, including under the Apprenticeships, Skills, Children and Learning Act 2009, and to create and maintain a unique learner number (ULN) and a personal learning record (PLR). The information you provide may be shared with other organisations for education, training, employment and well-being related purposes, including for research. You may be contacted after you have completed your programme of learning to establish whether you have entered employment or gone onto further training or education. You may be contacted by the English European Social Fund (ESF) Managing Authority, or its agents, to carry out research and evaluation to inform the effectiveness of the programme. Further information about use of and access to your personal data, and details of organisations with whom we regularly share data are available at:
https://www.gov.uk/government/publications/sfa-privacy-notice
Can we contact you?(if no please tick all appropriate below)
I do NOT wish to be contacted about courses or learning opportunities / ☐
I do NOT wish to be contacted for surveys and research / ☐
Do NOT contact me by Post / ☐ / Do NOT contact me by Phone / ☐ / Do NOT contact me by Email / ☐
Do NOT contact me by Text / ☐
Learners Agreement
· My goal is to complete the course and obtain the qualifications or learning objectives identified.
· I understand the importance of punctuality and will inform ACL staff in advance of any issues and the reason for this.
· I understand there is an expectation that I will attend 100% of the learning programme and will inform ACL staff in advance of any non-attendance and the reason for this.
· I understand the Health and Safety at Work procedures that apply to me and I will comply in respect of safeguarding the health and safety of myself and others and abide by the ACL equality and diversity policy.
· I am aware of how to raise concerns I may have related to safeguarding, extremism or radicalisation with an appropriate member of staff.
· I have seen or am aware of where to access a copy of the learner handbook and learner.
· I consent to ACL contacting me following my course to find out any job or progression outcomes and to receive guidance and further support in my learning or employment goals.
· I consent to ACL accessing my record on the Agency's Learning Records Service (LRS) to create and maintain a unique learner number and to confirm any prior learning I have undertaken.
· I understand that the programme I am enrolling on is subsidised by the Skills Funding Agency and it is a requirement of the funding rules that I complete and sign this learning agreement. Failure to do so will mean I will not be entitled to receive the SFA subsidy and that I will be required to pay the full cost of the programme.
· I understand that my course may be partly funded by the European Social fund.
Signed by (Learner) / Date:
Signed by (ACL Staff) / Date:
Visit us at: www.essex.gov.uk/Adult-Learning