PLEASE INDICATE YOUR ETHNIC ORIGIN (All Schools Are Required to Collect This Information)

PLEASE INDICATE YOUR ETHNIC ORIGIN (All schools are required to collect this information)

WHITE / BLACK OR BLACK BRITISH
English / Black Caribbean Background
Scottish / Ghanaian
Welsh / Nigerian
Other White British / Sierra Leonean
Irish / Somali
Traveller of Irish Heritage / Other Black African
Gypsy / Roma / Any Other Black Background
Please specify…………………………......
Italian
Any Other White Background
Please specify…………………………......
MIXED OR DUAL BACKGROUND / ASIAN OR ASIAN BRITISH
White and Black Caribbean
Indian
White and Black African
Pakistani
White and Pakistani
Bangladeshi
White and Indian
Asian and any other ethnic group
Any Other Mixed Background
Please specify ……………………..…...... / Please specify ……………………..…......
OTHER GROUPS
Chinese / Japanese / Any Other Ethnic Group
Please specify…………………………...... / I do not wish an ethnic category to be recorded
COUNTRY OF BIRTH ……………………………………………………………………………………………………………..

By submitting this application form, you are giving us permission to obtain a reference from your most recent school/college. Please contact us if you do not wish us to do this.

Applicant’s signature: ...... ………...... ………

Name: ...... ………...... …….. Date: ......

PLEASE PRINT IN CAPITAL LETTERS)

/ Stantonbury Campus Sixth Form
Application form for admission – September 2018

Please complete all sections using BLOCKCAPITAL letters and in blue or black ink – thank you

STUDENT DETAILS

Are you currently studying at Stantonbury? Yes/No If yes, which is your tutor group? 11____
If no, have you ever studied at Stantonbury before? Yes/No
LEGAL SURNAME: / FORENAME:
(Birth Certificate or Change of Name by Deed Poll) / MIDDLE NAME/S:
DATE OFBIRTH: / NATIONALITY:
(as shown on Birth Certificate or Passport) / RELIGION :
(if applicable)
HOME LANGUAGE: / MALE / FEMALE (Please delete as appropriate)
ADDRESS:
POST CODE: / HOME TEL:
E-MAIL ADDRESS:

1ST CONTACT – PARENT OR CARER AT THE SAME ADDRESS AS ABOVE

TITLE: / FORENAME: / SURNAME:
PLEASE TICK RELATIONSHIP TO YOU: PARENT □ CARER □ STEP-PARENT □ AUNT □ UNCLE □
PARENT’S PARTNER □ OTHER (please specify)…………………………………………………………………......
WORK TEL: / MOBILE TEL: / HOME TEL:
E-MAIL ADDRESS:
PLEASE NOTE THAT IF YOU PROVIDE AN E-MAIL ADDRESS THIS IS WHAT WE WILL USE FOR THE MAJORITY OF ALL CORRESPONDENCE

2ND CONTACT – PARENT OR CARER

TITLE: / FORENAME: / SURNAME:
ADDRESS (IF DIFFERENT)
Post code:
PLEASE TICK RELATIONSHIP TO YOU: PARENT □ CARER □ STEP-PARENT □ AUNT □ UNCLE □
PARENT’S PARTNER □ OTHER (please specify)…………………………………………………………………......
WORK TEL: / MOBILE TEL: / HOME TEL:
E-MAIL ADDRESS:
PLEASE NOTE THAT IF YOU PROVIDE AN E-MAIL ADDRESS THIS IS WHAT WE WILL USE FOR THE MAJORITY OF ALL CORRESPONDENCE
If this parent is living elsewhere, will they require reports? Yes/No

NEXT CONTACT

TITLE: / FORENAME: / SURNAME:
ADDRESS
POST CODE:
RELATIONSHIP TO YOU:
WORK TEL: / MOBILE TEL: / HOME TEL:
IF THIS CONTACT IS A PARENT PLEASE PROVIDE AN E-MAIL ADDRESS:

MEDICAL INFORMATION – please complete all relevant sections

Name of yourMedical Centre:-
Do you have mobility difficulties?
If ‘Yes’ please provide details:- / Yes / No
If you have a medical condition please enter full details below, continuing on a separate sheet if necessary
MEDICAL CONDITION / SYMPTOMS / Date of Diagnosis
Do you take regular prescribed medication?
If ‘Yes’ please provide full details here and advise whether it will need to be taken during the school day:- / Yes / No

SPECIAL NEEDS

Do you have an Educational Health Care Plan / Yes / No
Have you ever received learning support? / Yes / No
Are there other aspects of learning we should know about? / Yes / No

QUALIFICATION DETAILS – What qualifications do you have or are you working towards?

EXAM DETAILS
(Exam board, month and year) / QUALIFICATION
TYPE
GCSE/BTEC / SUBJECT

PREVIOUS SCHOOL DETAILS

School Name:
Name of Tutor:
Dates (From – To):

ROUTE OF PREFERENCE

BLOCK A / BLOCK B / BLOCK C / BLOCK D

ENRICHMENT

1st choice / 2nd choice

APPLICATION DETAILS

Please provide relevant details to support your application and your chosen course of study. Include details of education abroad; additional exams and any long periods of absence. Please use another sheet of paper if you need to.