Learner Application Form

The information requested on this application form is required and used by DKM to make an informed decision on which learning programme and qualification is most suited to you. All records are stored safely and only approved staff and partners are authorised to access.

1.  / PERSONAL DETAILS
Name
(please print your name as you would like it to appear on any certificates)
Address / Post code
National Insurance Number
Home Telephone / Date of Birth
Mobile Telephone / Age / Gender
Email Address
Qualification/ Apprenticeship/ Programme applying for:
Are you an Overseas National?
(If the answer is yes, further eligibility checks and supporting evidence of right to abode will be required) / How long have you been a resident in the UK?
Are you in receipt of any type of benefit? Please state.
Yes / No
If Yes, Please tick below;
Job Seekers Allowance (JSA)
Employment and Support Allowance – Work related Activity Group (ESA (WRAG))
Other state benefit other than JSA, Universal Credit or ESA (WRAG)
Universal Credit
Current Status:
Employed / Non Employed / Self Employed / Volunteer
College / School / Other
If employed, Length of Employment
Up to 3 months / 7-12 months
4-6 months / Over 12 months
If Non-Employed, Length of Unemployment
Less than 6 months / 12-23 months / Over 36 months
6-11 months / 24-35 months
Please tick your ethnicity:
31. White British / 41. Bangladeshi
32. White Irish / 42. Chinese
33. Gypsy or Irish Traveller / 43. Other Asian
34. Any Other White Background / 44. Black African
35. Mixed White & Black Caribbean / 45. Black Caribbean
36. Mixed White & Black African / 46. Black Other
37. Mixed White & Asian / 47. Arab
38. Any Other Mixed Background / 98. Any Other
39. Indian / 99. Not Known/Not Provided
40. Pakistani
Do you have any physical or mental health difficulties that may affect your learning?
Please tick appropriate / 1 / Visual Impairment
2 / Hearing Impairment
3 / Disability Affecting Mobility
4 / Other Physical Disability
5 / Other Medical Condition (Epilepsy/Asthma/Diabetes)
6 / Emotional/Behavioural Difficulties
7 / Mental Health Difficulty
8 / Temporary Disability after illness or accident
9 / Profound Complex Disabilities
10 / Asperger’s Syndrome
90 / Multiple Disabilities
97 / Other
98 / None
Are you at present having any medicine, injections, tablets or other treatment prescribed by a doctor that may affect you?
Are you registered disabled?
Do you have any learning disabilities?
Please tick appropriate / 1 / Moderate Learning Difficulties
2 / Severe Learning Difficulties
10 / Dyslexia
11 / Dyscalculia
19 / Other Specific Learning Difficulty
20 / Autism Spectrum Disorder
90 / Multiple Learning Difficulties
97 / Other
98 / None
How many days have you been absent from work, college or school due to illness over the last 3 years?
What was your final school year attendance percentage? (school leaver only)
Emergency Contact Details
Doctor’s name and practice
Have you undertaken any certificated health and safety training other than general induction? (please detail)
Because the nature of our business involves working with young people and vulnerable adults, in the interest of safeguarding, we require you to disclose all previous convictions that are not required spent under the Rehabilitation of Offenders Act 1974 (this includes any previous offence, spent or otherwise, that excludes you working with children and young people).
Do you have any cautions, bind over orders or convictions? / Yes / No
If you answered yes, please give details
Please tick if you have any disabilities that affect:
Climbing ladders / Use of your hands
Climbing stairs / Walking
Driving a motor vehicle / Working on staging
Lifting / Working on heights
Standing / Other (Please State)
Do you require support at your interview?
If yes, please provide details.
Do you require support whilst on your qualification/programme?
(ie: Childcare/learning support/financial)*

* A separate assessment may be required to support this.

2.  EMPLOYER DETAILS (if Non Employed Leave Blank)
Company Name:
Address:
Post Code:
Telephone:
Job Title
Manager’s Name:
Manager’s Job Title:
Hours per Week (if less than 30 hrs per week, authorisation from funding body will be required)
Email Address:
Is your job Permanent or Temporary?
Have you discussed undertaking a qualification with your employer?
Do you have a written Contract of Employment and Job Description and are you able to provide copies of these if required? / Start Date with Employer
Did you have an induction to your workplace upon starting?
3.  EMPLOYMENT HISTORY & WORK EXPERIENCE
Dates / Employer or Company / Job Title
4.  EDUCATION & TRAINING (if none, please enter NONE)
Dates / College or Provider / Qualification / Grades/Level
5.  ADDITIONAL INFORMATION
Why have you applied for this qualification/Apprenticeship/programme?
Where did you hear about us?
What are your career aims?
What are your hobbies and interests?
Personal Statement (Include here any further information about yourself which you believe to be pertinent to your application.)
Would you be interested in undertaking an E-portfolio?
Do you have any other commitments that may affect your learning? (eg dependents, housing issues, child care, carer etc)
Do you have a driving licence? / Do you have access to a vehicle?
Any other additional information (eg religious/beliefs, dietary, accessibility /adaptations etc)?
6.  EQUALITY AND DIVERSITY
What is your understanding of Equality and Diversity? Further information on Equality and Diversity will be provided at your induction
7.  HEALTH AND SAFETY
What is your understanding of Health and Safety? Further information on Health and Safety will be provided at your induction
8.  SAFEGUARDING
What is your understanding of Safeguarding?
Further information on Safeguarding will be provided at your induction
9.  REFEREE
Name of referee / Position / Address / Telephone number
10.  RESIDENCY
The following persons will be eligible for funding, please tick the appropriate statement.
A person on the relevant date who is “settled” in the UK, and who has been ordinarily resident in the UK and Islands (that is, including the Channel islands and the Isle of Man) for the three years preceding the relevant date and whose main purpose for such residence was not to receive full-time education during any part of the three-year period. “Settled” means having either Indefinite Leave to Enter or Remain (ILE/R) or having the right of abode in the UK;
British citizens and certain other citizens have the right of abode in the UK:
i.  persons with European Community – United Kingdom of Great Britain and Northern Ireland Passports;
ii.  British Dependent Territory Citizens (now known as British Overseas Territory Citizens);
iii.  those whose passports have been endorsed to show they have Right of Abode in the UK;
iv.  those who have a certificate of naturalisation or registration as a British Citizen.
A national of any European Union (EU) country or the spouse, civil partner or child or grandchild or dependant parent or grandparent of an EU national, or of the EU national’s spouse or civil partner, where the learner has been ordinarily resident in the European Economic Area (EEA) for the three years preceding the ‘relevant date.’
An EEA migrant worker or the spouse, civil partner or child or dependant parent or grandparent of an EEA migrant worker, or of the EEA migrant worker’s spouse or civil partner, where the learner has been ordinarily resident in the EEA for the three years preceding the ‘relevant date.’
Anyone who is recognised as a refugee by the UK Government (granted Refugee Status) who has remained ordinarily resident in the UK and Islands since so recognised, or the spouse or civil partner or child of such a refugee;
Anyone refused Refugee Status but who has been granted leave to stay by the Secretary of State, granted humanitarian protection (HP) or discretionary leave (DL), or was granted exceptional leave to enter or remain (ELE/ELR) by the UK Government, and has remained ordinarily resident in the UK and Islands since so recognised, or the spouse, civil partner or child of such a person;
Learners studying under reciprocal exchange agreements.
Learner who are children of Swiss nationals where the learner has been resident in the EEA for the full Three-year period prior to the commencement of their programme.
Learner who are children of Turkish workers where the Turkish worker has been lawfully employed and resident in the UK at any time in the past and where the learner has been resident in the EEA and Turkey for the full three-year period prior to the commencement of their programme.
11. PAYMENT DETAILS
Please tick who will be paying for your qualification/programme (Tick all that apply):
Self*
Employer*
Publicly Funded
24+ Advanced Learning Loans**

** Application to the Student Loan Company must be made using information from the Information and Funding Letter to be provided by the provider.

12. *INVOICE DETAILS (If you have selected self or Employer payment)
Invoice Address:
Postcode:
Contact: / Contact Number:
Purchase Order Number: (if applicable)
13. DATA PROTECTION STATEMENT
This data is held securely both in hard copy and electronic copy. This data is used to compile reports and statistics that comply with contractual requirements and for general administration purposes, including evaluation questionnaires. It may be disclosed to third parties such as Government funding bodies. Please note data will not be disclosed to any commercial agency. We will supply you with a copy of the data that we hold about you upon written application. A list of third parties to whom we disclose personal data is available upon request. Please be aware that all information held is only available to, and handled by authorised members of staff.
The information you supply will be used by the Skills Funding Agency, to issue you with a Unique Learner Number (ULN), and to create your Personal Learning Record. Further details of how your information is processed and shared can be found at www.learningrecordsservice.org.uk/privacynotice
Please tick any of the following boxes if you do not wish to be contacted;
About courses or learning opportunities / For surveys and research / By post / By phone / By
e-mail
14. LEARNER DECLARATION
I confirm that all the information on this form is correct and I declare that I have correctly identified my prior qualifications and residency. I understand that if I have declared false information, the provider may take action against me to reclaim the tuition fees and any support costs provided. I consent to the collection and use of my personal data as set out above.
I confirm that the activity that I participate in may be part-financed by the European Union through the European Social Fund (ESF). ESF Supports activities to extend employment opportunities and develop a skilled workforce.
Learner Name
Signature / Date
15. EMPLOYER DECLARATION (if applicable)
I can confirm that, to the best of my knowledge, the information on this form is correct. If the above named learner is employed by me, I declare that they have a contract of employment. I consent to the collection and use of company data as set out above.
Employer Name
Signature / Date
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