This Application Form Is for Application For

Graduate Certificate Practice Educator Professional Standards.

This application form is for application for:

Graduate Certificate Practice Educator Professional Standards (PEPS),

A Programme for Professionals in Enabling and Supporting Work Based Learning.

PEPS1 Module – Friday 20 May, 27 May and 3 June , Friday 14 October,

21 October, 28 October 2016

PEPS2 Module – 3 days in October 2017 tbc

Please complete all relevant sections of this form. Incomplete applications will be returned.

Completed applications should be returned, preferably by email, to

or sent to:

Oxfordshire Practice Learning Centre,

Ruskin College,

Dunstan Road,

Old Headington,

Oxford

OX3 9BZ

If you need assistance filling in this form please call 01865 759630 or email (above)

APPLICATION FORM

Personal Details

Title: Forename(s): Preferred name:______

Surname: Date of Birth:

Telephone number (including dialling code) Day: Mobile:______

Address: ______

______Postcode:______

Email address: ______

CRB Disclosure

CRB Disclosure number:
Date issued:
Authorising body:

Social Work HCPC Registration number:

Educational History

Please tell us about any Higher Education and social work qualification you hold (including PQ)

Date From / Date to / Organisation / HEI / Subject / Qualification

Post Qualification Employment History

Date From / Date to / Organisation / Position Held

Has your current employer sponsored you to attend this course? Yes  No o

If not, how will you be funding this programme

Please give details. (This is so we can arrange for invoicing )

Data protection

Ruskin College collects information about all our staff and students for various administrative, academic

and health and safety reasons. Under the Data Protection Act 1998, we need your consent before we

can do this. Since we cannot operate the College effectively without processing information about our

students, we need you to sign the following consent to process personal data. If you require further

information about this, please contact the Academic Registrar.

I agree to Ruskin College processing person data contained in this form or other data which the

College may obtain from me or other people, whilst I am a student. I agree to the processing

of such data for any purpose connected with my studies or my health and safety whilst on the

premises, for the purpose of anonymised data analysis or of any other legitimate reason

Under representation

Ruskin College particularly welcomes students from backgrounds under-represented in education. It

would help us to monitor our inclusivity if you could tick any of the boxes that are relevant to you. This

information is analysed across whole student groups and is never made public in a way that could

connect it with any particular individual. It may be shared in College on a ‘need to know basis’, in order

to offer you support or advice. You may tick more than one box.

Do any of the following apply to you? (tick all that apply)

Homeless / Refugee
Traveller / Recovering from alcohol or drug dependency
Asylum Seeker / Mental health problems
Full-time carer for dependant relative at home / Living in a hostel or residential centre
Ex-offender / Statutory education interrupted
Currently in care or a care leaver*(Please state local authority if under 25yrs,*There may be additional support available to you if you are currently in care or have been a care leaver.)

Sensitive data

I (name): ______

Give my consent to Ruskin College recording and processing information about me in the following

categories (Please tick each box for which you give permission, ideally all 5 boxes unless you object):

(1) Ethnic origin

(2) Membership of a trade union

(3) Physical or mental health or medical

(4) Criminal record

(5) Country of birth and nationality

Purpose & Information Category (in brackets)

Checking suitability and fitness for course places (3,4)

Managing and maintaining a safe college environment (3,4)

Managing duties and obligations under the Equality Act 2010 (3)

Administering scholarship agreements (2)

Monitoring college performance against targets (1,5)

Assessing student support needs (3)

Assessing funding eligibility (5)

I understand that this information will be used only for the purposes set out in the statement

above and my consent is conditional upon Ruskin College complying with its obligations and

duties under the Data Protection Act 1998.

Signature: ______Date: ______

Monitoring Information

Completion of this page is voluntary, but to help us monitor our policies and practices in relation to

equalities and diversity, you are asked to provide the information requested below. This information is

confidential and does not form part of your application. This slip will be detached from your application form when it is received and the information will not be taken into account when your application is considered.

Surname: ______Initials: ______Are you: Male o Female

Course level and subject (eg CertHe History): ______

Disability Statement

The College takes reasonable steps to find out whether you have any disabilities so as not to treat

disabled students less favourably than other students and to make reasonable adjustments where required. You may choose not to disclose any disability you may have, but you should recognise that this

could mean we are not able to support you fully in your studies.

Disability or Special Needs (please tick all that apply)

Visual impairment
Mental health difficulties
Hearing impairment
Temporary disability after illness or accident
Disability affecting mobility
Profound complex disabilities
Other physical disability
Aspergers syndrome or autistic spectrum
Other long-term medical condition e.g. epilepsy, asthma, diabetes
Multiple disabilities
Emotional / behavioural difficulties including ADHD
Please state if you care for a disabled dependant at home
Other (please state)

To which of these groups do you consider you belong? (tick one only)

Asian or Asian British - Bangladeshi
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - any other Asian background
Black or Black British - African
Black or Black British - Caribbean
Black or Black British - any other Black background
Chinese
Dual - White and Asian
Dual - White and Black
Caribbean
Dual - White and Black African
Dual - any other heritage
White - British
White - Irish
White - any other White background
British National Overseas
Other (specify)

Have you resided in the UK for three years immediately prior to your application? Yes No o

Have you been:

ordinarily resident

free from immigration conditions o

settled in the UK for the three years immediately prior to your application o?

(please tick the statement which applies to you)

Do you have refugee status? Yes o No Not applicable

Do you regard yourself as belonging to any particular religion or belief system? Yes No o

If yes, what religion, religious denomination or belief system do you belong to: ______

Do you consider your sexual orientation to be: Bisexual o Gay / Lesbian o Heterosexual

Do you have Gender Dysphoria i.e. are you transgendered or feel that you need to be? Yes o No

Age

18 years and under o 19 - 25 years o 26 - 35 years 36 - 45 years o

46 - 55 years o 56 - 59 years o 60 - 65 years o 66 years and aboveo

Thank you

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