St Cuthbert Mayne Sixth Form

ST CUTHBERT MAYNE SIXTH FORM

APPLICATION FORM SEPT 2018

PLEASE COMPLETE IN BLACK INK

1. PUPIL DETAILS
SURNAME: / FIRST NAMES:
DATE OF BIRTH: / AGE ON 01.09.18
GENDER: MALE/FEMALE
(Delete as Applicable) / YOUR MOBILE NUMBER:
Email Address: / Nationality:
Country Of Birth:
RELIGIOUS DENOMINATION:
2. PARENT/GUARDIAN DETAILS
Please give details of ALL persons with parental responsibility
NAME OF PARENTS/GUARDIANS:
RELATIONSHIP TO STUDENT:
RELATIONSHIP TO STUDENT:
RELATIONSHIP TO STUDENT:
HOME ADDRESS:
POSTCODE: HOME TELEPHONE:
Please give address details of any Parent/Guardian living at a different address who wishes to receive a copy of school correspondence
NAME OF PARENT/GUARDIAN:
RELATIONSHIP TO STUDENT:
ADDRESS:
POST CODE:
3. CONTACT PERSONS IN DAYTIME EMERGENCY
Please give details of 3 contacts for a possible Emergency during school hours
Priority 1
NAME: RELATIONSHIP TO STUDENT:
TELEPHONE: WORK/HOME(delete as appropriate):
(if work details – please include company name)
ADDRESS:
EMAIL: MOBILE:
Priority 2
NAME: RELATIONSHIP TO STUDENT:
TELEPHONE: WORK/HOME(delete as appropriate):
(if work details – please include company name)
ADDRESS:
EMAIL MOBILE:
Priority 3
NAME: RELATIONSHIP TO STUDENT:
TELEPHONE: WORK/HOME(delete as appropriate):
(if work details – please include company name)
ADDRESS:
EMAIL : MOBILE:
4. CULTURAL INFORMATION (Requested by the DfES)
ETHNIC ORIGIN / ETHNIC ORIGIN / HOME LANGUAGE / HOME LANGUAGE
White British / Asian or Asian British - Pakistani / Bengali / Mandarin
White Irish / Asian or Asian British - Bangladeshi / Cantonese / Punjabi
White Other White background / Asian or Asian British - Other / Chinese / Polish
Mixed White and Black Caribbean / Black or Black British – Caribbean / English / Spanish
Mixed White and Black African / Black or Black British - Other / French / Turkish
Mixed White & Asian / Chinese / Greek / Urdu
Mixed Other mixed background / Other Ethnic Group: / Hindi / Other Language:
Asian or Asian British - Indian / Italian
5. MEDICAL INFORMATION
DOCTORS NAME: TELEPHONE:
MEDICAL PRACTICE ADDRESS:
Do you have special medical needs?YES/NO (delete as applicable)If Yes please specify:
Special Medical Needs such as: Allergies – Diabetes – Asthma – Epilepsy - Medication
6. S E N
SPECIAL EDUCATION SUPPORT REQUIREMENT (SEN)
Do you have a Special Educational Need? YES/NO (delete as applicable)
If Yes please specify:
Special Education Needs such as:Dyslexia or a Physical Disability(help us support you)
7. EXAM CONCESSIONS
Do you have or have you been given exam concessions – if so please describe (evidence will be recalled from your previous school)
8. EDUCATIONAL DETAILS
PRESENT SCHOOL/COLLEGE LAST ATTENDED:
ADDRESS: / DATE LEFT/LEAVING
9. SUBJECTS CURRENTLY STUDYING
PLEASE LIST THE SUBJECTS THAT YOU ARE CURRENTLY STUDYING OR HAVE COMPLETED
SUBJECTS STUDYING
AT PRESENT / Mock Grade/Level / Predicted
Grade/Level / SUBJECTS STUDYING
AT PRESENT / Mock Grade/Level / Predicted Grade/Level
English Language
English Literature
Mathematics
Science (Core)
Science (Additional)
10. ABOUT YOURSELF
USING BOXES BELOW – PLEASE TELL US A LITTLE ABOUT YOURSELF
Hobbies & Interests – Sport Team Involvement – Music & Drama Achievements - Work Experience – Positions Of Responsibility at work/school/clubs
Do you have Career Plans?
If Yes, how do you think your chosen subjects will help you achieve your career plans?
11. OPTIONS
You can choose from 3 options at St Cuthbert Mayne Sixth Form:

Pre A Levels, a one year course for those students wishing to prepare for A level study
BTEC Business Studies plus an additional subject
A Levels, students will choose 3 subjects (or 3 if they need to do re-sits of English or Maths)

Please choose from one of the options as listed below
OPTION 1 – PRE ‘A’ LEVELS
(If you choose this option the subjects run across all blocks)
Please tick
PRE A LEVELS
OPTION 2 – BTEC BUSINESS STUDIES
(This course covers 2 option blocks so you must also choose an additional subject from the list below)
Please tick 1 option from those below
Btec Business Studies with Chemistry / Btec Business Studies with Media Studies
Btec Business Studies with Philosophy & Ethics / Btec Business Studies with English Literature
Btec Business Studies with Maths / Btec Business Studies with Btec P.E.
Btec Business Studies with I.T. / Btec Business Studies with English Language
Btec Business Studies with History / Btec Business Studies with Psychology
Btec Business Studies with Performing Arts
OPTION 3 – ‘A’ LEVELS
PLEASE NOTE:
It is not always possible to accommodate all combinations of subjects.
It is not always possible to offer a subject if the numbers are very low
Students who have not passedEnglish Language, Science and/or Mathematics at GCSE will be expected to
take extra lessons in these subjects and re-take the exam(s) during their first year in the Sixth Form.
PLEASE TICK (4)SUBJECTS- EACH MUST BE FROM A DIFFERENT BLOCK.
A /  / B /  / C /  / D /  / E / 
Chemistry / English Literature / Geography / Information Technology / Art
Btec Health & Social Care – Part 1 & 2 / Mathematics / Psychology / English Language / Biology
Media Sudies / Btec P.E / Photography / Btec Health & Social Care – Part 2 of 2 / Business Studies
Philosophy & Ethics / History / Sociology
Psychology
Btec Performing Arts
12. WHICH SIXTH FORM / COLLEGE CHOICE
If you have chosen to apply to other Sixth Forms or Colleges - please state choices in order of preference:
1st Choice
2nd Choice
3rd Choice
Please note that this does not affect your application, it is simply for lesson planning purposes.
13. STUDENT & PARENT SIGNATURES
STUDENT SIGNATURE:
Signed: Date:
PARENT / GUARDIAN SIGNATURE:
Signed: Date:
14. EXTERNAL STUDENTS ONLY
EXTERNALSTUDENTS ONLY
Please supply a name of a referee, which should be your Headteacher or Head of Year if possible.
NAME:POSITION:
ADDRESS:
TELEPHONE:

PLEASE RETURN TO:

KIRSTY MILLS, SIXTH FORM OFFICE, ST CUTHBERT MAYNE SCHOOL,

TRUMLANDS ROAD, TORQUAY, TQ1 4RN

Tel: 01803 328725 or Email:

Christ is our Cornerstone - Learning is our Focus