Southwark Adult Learning Service

External Partner Groups 2010/11

Enrolment Form and Learning Agreement

Please complete this form in BLOCK CAPITALS.

Personal Details:
Title(please circle) / Other / Last name
Mr / Mrs / Ms / Miss / First name(s)
Full address
Postcode / Telephone
Email address / Date of birth
D / D / M / M / Y / Y / Y / Y
male / female / Contact in case of emergency / name
telephone
We require the following information for funding purposes:[note: all learners must provide evidence of eligibility including UK residents]
a) / How long have you lived in the UK? How many / years / months Or whole life
b) / If you have lived outside the UK in the last 3 years, please tick any of the following that apply to you:
British or EU passport holder / Granted leave to remain indefinitely
Resident on student or visitors visa / Asylum seeker or refugee
Other, please specify / 1
Partner Staff Use: : evidence of eligibility must be checked for all learners whether they tick a) or b) – this may include a valid passport, driver’s licence, council tax bill, or two utility bills. Please state which forms of evidence have been shown and initial. If a passport or driver’s licence is seen the number must be recorded.
Specify eligibility evidence seen: / Staff initials
(NB passports and driver’s licence numbers must be recorded)
Equal Opportunities Monitoring: What is your ethnic origin?(Please tick the appropriate box)[L12]
11 / Asian or Asian British - Bangladeshi / 19 / Mixed – White and Asian
12 / Asian or Asian British - Indian / 20 / Mixed – White and Black African
13 / Asian or Asian British - Pakistani / 21 / Mixed – White and Black Caribbean
14 / Asian or Asian British – any other Asian background / 22 / Mixed – any other Mixed background
15 / Black or black British - African / 23 / White - British
16 / Black or black British - Caribbean / 24 / White - Irish
17 / Black or black British – any other Black background / 25 / White – any other White background
18 / Chinese / 98 / Any other
99 / Not known / prefer not to say / not provided
What is the highest level you have achieved in your previous learning?[L35]
09 / Entry level
07 / Other qualifications below level 1
01 / Level 1: GCSE / O levels grades D-G, CSE below grade 1, GNVQ foundation level, NVQ level 1
02 / Full level 2: GCSE / O levels grades A-C, CSEs grade 1, GNVQs Intermediate, NVQ level 2
03 / Full level 3: 2 or more A levels, 4 or more AS levels, GNVQ advanced
04 / Level 4: Teaching qualifications, degree, HNC or HND, NVQ level 4, Nursing SRN
05 / Level 5 and above: Higher Degree, NVQ level 5, Masters, doctorate
97 / Other qualification, level not known
98 / Not known
99 / No qualifications
Entered on DB by (SALS staff initials)
date
Disabilities and learning difficulties:
We would like to give you the support you need to attend our classes. Do you consider yourself to have a learning difficulty and/or disability and/or health issue?[L14]
1 / YES / 2 / NO / 9 / Prefer not to say
If yes, please select any that apply to you from the boxes below:
L15 / L16
01 / Visual impairment / 01 / Moderate learning difficulty
02 / Hearing impairment / 02 / Severe learning difficulty
03 / Disability affecting mobility / 10 / Dyslexia
04 / Other physical disability / 11 / Dyscalculia
05 / Other medical condition (e.g. epilepsy, asthma, diabetes) / 19 / Other specific learning difficulty
06 / Emotional / behavioural difficulties / 20 / Autism spectrum disorder
07 / Mental health difficulties / 90 / Multiple learning difficulties
08 / Temporary disability after illness (e.g. post-viral) or accident / 97 / Other
09 / Profound complex disabilities / 98 / No learning difficulty
10 / Aspergers Syndrome / 99 / Not known / prefer not to say
90 / Multiple disabilities / Disclosure of disabilities and learning difficulties
97 / Other / It may be helpful for your tutor to have this information. Are you happy for this information to be passed onto them?
98 / No disability
99 / Not known / prefer not to say / not provided / YES / NO
You may wish to discuss your needs with your tutor so we can make reasonable adjustments to support your learning.
PEEP / Please tick if you need assistance to exit the building in the event of an emergency evacuation. Staff will prepare a Personal Emergency Evacuation Plan for you.
How did you find out about this course?
In person or by phone / Friend or family member
Prospectus or leaflet / Local library
Other (please specify)

Which course would you like to enrol on:

Course code / Course title / Learner’s start date(normally first day of course)

Data Protection Act 1998

The personal information you provide is passed to the Chief Executive of Skills Funding and, where required, the Young People’s Learning Agency for England (“the YPLA”) to enable those organisations to fulfil their statutory obligations, principally under the Apprenticeships, Skills, Children and Learning Act 2009. Both organisations are registered as data controllers with the UK Information Commissioner’s Office.The Skills Funding Agency funds adult further education and skills training, including apprenticeships, in England. The YPLA is responsible for arranging the provision of funding for the education and training of young people in England. The Skills Funding Agency processes learner data on behalf of the YPLA.The information you provide may be shared with other organisations for purposes of administration, the provision of career and other guidance and statistical and research purposes, relating to education or training. Other organisations include the Department for Education, the Department for Business, Innovation and Skills, Local Authorities, Connexions, Higher Education Statistics Agency, Higher Education Funding Council for England, educational institutions and organisations performing research and statistical work on behalf of the Skills Funding Agency, the YPLA, or partners of those organisations. The Skills Funding Agency also administers the learner registration service (LRS) which uses your learner information to create and maintain a unique learner number (ULN). Further information about use of and access to your information is available at: Skills Funding Agency: YPLA: no time will your personal information be passed to organisations for marketing or sales purposes. The YPLA, the Chief Executive of Skills Funding and their partners may wish to contact you from time to time in respect of surveys and research to monitor performance, improve quality and plan future provision and to inform you about courses, or learning opportunities relevant to you.

Tick this box if you do not wish to be contacted in respect of surveys and research by mail or phone.

Tick this box if you do not wish to be contacted about courses or learning opportunities by post

Student Declaration and Learning Agreement
  • I confirm that the information I have provided on this form is correct. I understand that I have signed up to attend the learning programme detailed above. I undertake to attend regularly and punctually on all courses that I have enrolled for.

Student signature / date
SALS staff signature / date