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Application form

 

 

Enrolment Form

 

Provider Name

YOUTH EDUCARE

Sign up Date

 

Provider UKPRN

10047156

Allocated Assessor

 

Course Name

                                                           CODE:

 

Section 1a: Learner Details

 

Title:

Female

Male

Date of Birth:      00 /   00   /    0000

 

First Name:

Family Name:

NI Number:

Email Address:

Address Line 1:

Town:                                             County:                                                       Postcode:

Mobile:                                                                       Telephone:

Do you have a Unique Learner Number?

Is there a related Age Grant application?

If learner does not have a ULN, Please indicate what type of evidence you have seen to prove ID?

Passport

Driving Licence

      Exam Certificate  

Nl Card    

Other

 

Passport Number :

Start Date :

Place of Birth:

Expiry Date :

 

   Section 1b: Eligibility Details

 

 

Has the learner been a full resident in England or the EU/EEA (excluding Wales, Scotland and Northern Ireland) throughout the last 3 years for purposes other than study?

If No, what was your Previous country of residence?   

What is your nationality? (What passport do you hold?)  

British Citizen                  EU /EEA                

Other, Please State :

Date of entry to UK [if not born here]:

If your passport type is ‘other’, please state what type of visa/leave to remain in the UK do you have?

If you were not born in the UK/EU/EEA and have not been resident for the last 3 years, we need to confirm your entitlement to receive government funding for your training programme. To ensure you fulfil the government Skills Funding Agency’s residency criteria we may require additional information to show you have a right of abode. Tick evidence seen

Passport endorsed with leave to remain

 Biometric Residence Card              

Visa with no restrictions

 

Letter from Home Office (UK Border Agency) confirming refugee status

 

Certificate of naturalisation or registration as British Citizen

 

 

 

Section 1c: Which programme are you applying for?

New qualification to complete 

 

 

At Level:

 

Learning Aim Reference

 

Planned Working Hours for Course

 

Learning Start Date

 

Learning End Date

 

Learning Actual End Box

 

Delivery Location Postcode

 

 

 

Section 2a: Prior Qualifications

All learners must provide detail of all prior qualifications and any other form of study below. If the learner has no qualifications please state ‘None’. Please continue onto another sheet of paper if required.

Subject

Level of Study

 

Grade

 

Date Achieved

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 2b: Learner Employment Status (Please Tick)

 

 

Employed

 

 

Job Title

 

In Paid Employment

 

Self Employed

 

Start Date

 

Hours Per Week

 

 

Unemployed

 

 

Section 3: Ethnicity

How would you describe your ethnic origin or personal identity?

We are required to obtain this information to monitor the implementation of our Equality & Diversity Policy in relation to the Equality Act using the Government classification of Ethnicity.

 

Please Tick your Ethnicity

English / Welsh / Scottish / Northern Irish / British (31)

 

Bangladeshi (41)

 

Irish (32)

 

Chinese (42)

 

Gypsy or Irish Traveller (33)

 

Any other Asian background (43)

 

Any Other White Background (34)

 

African (44)

 

White and Black Caribbean (35)

 

Caribbean (45))

 

White and Black African (36)

 

Any other Black / African / Caribbean background (46)

 

White and Asian (37)

 

Arab (47)

 

Any other mixed / multiple ethnic

background (38)

 

Any other ethnic group (98)

 

Indian (39)

 

Not provided (99)

 

Pakistani (40)

 

 

 

 

Section 4: Support Requirements

 

All learner need to complete the below. We require this information to ensure that any support you need is available to you.  Please indicate any disabilities, learning difficulties and/or health problem.

 

 

Visual impairment

 

Moderate learning difficulty

 

Hearing impairment

 

Severe learning difficulty

 

Disability affecting mobility

 

Dyslexia

 

Other physical disability

 

Dyscalculia

 

Other medical condition(for example, epilepsy, asthma, diabetes)

 

Other specific learning difficulty

 

Social and emotional difficulties

 

Autism spectrum disorder

 

Mental health difficulty

 

Other Learning difficulty

 

Temporary disability after illness (for example post-viral) or accident

 

None

 

Profound complex disabilities

 

Not provided

 

Asperger’s syndrome

 

 

 

Other disability

 

 

 

Please indicate which of the above is your PRIMARY disability, learning difficulty and/or health problem

 

 

 

Section 5: Household Situation

 

 

Please tick which the following statement apply (one or more may apply)

 

No member of the household in which I live (including myself) is employed

 

The household that I live in includes only one adult (aged 18 or over)

 

There are one or more dependent children (aged 0 -17 years or 18-24 years if full time student or inactive) in household

 

Lone or Teenage Parent household situation

 

Carer or Care Leaver

 

I confirm that I wish to withhold this information

 

None of these statements apply

 

Section:6     Please provide two alternative contacts

1:

Surname:

First name (s):

Relation:                                                                  phone:

Address:

                                                                                Post Code:

 

2

Surname:

First name (s):

Relation:                                                                  Phone:

Address:

                                                                                 Post Code:

 

Section:7  CONVICTIONS

 

Do you have any criminal conviction?                       Yes                     No

If you have not been convicted of a criminal offence you must tick the ‘No’ box.

Give details and please provide necessary documents if you tick ‘Yes’ box.

 

 

 

 

 

      Section:8          DATA PROTECTION ACT:

 

 

The information you supply on this form will be used by YOUTH EDUCARE in accordance with the Data Protection Act 1998 and other applicable legislation. The institution will use the information to process your application and to provide any relevant further information by post, email or text. It will also be used to support the institutions’ marketing and market research activities.

 

Please tick if you do not wish to receive further information by

Post            Text               Email           Phone

If at any time you change your mind and you would like the institution to stop sending such information, please contact the administration or email admin@youtheducare.com

The information from your application form will be used to set up a student record on the institution’s student information (SI) system. Where required this information may be shared with the government or their respective agents to check the accuracy of personal information provided by students against external data sources such as the Higher Education Statistics Agency (HESA), or the Learning Skills Council Individual Learner Record (LSC ILR), returns. The institution may also contact other institutions to confirm previous qualifications obtained.

In order to prevent and detect fraud and comply with regulations for international students we reserve the right to, or may be required to, share this information with external organisations such as the police, the Home Office, the Foreign and Commonwealth Office, the UK Visa’s and Immigration and local authorities.

 

I consent to the Home Office, or related Government agency, releasing information about my immigration history to     the YOUTH EDUCARE for these purposes. This may include sensitive personal data about any orders, warnings, convictions or other penalties relevant to immigration. (Please note that failure to provide consent by ticking the above box may delay the processing of your application.)

 

 

Section:9   DECLARATION

 

 

I confirm that the information I have given on the enrolment form is correct and declare that I have correctly identified my prior qualifications, eligibility for this programme and validated my identity. I have read and understood the contents of this agreement. I also confirm that this document is an original document. I have read the important information regarding my responsibility for payment of fees and agree to pay fees as stated above. 

Learner Signature: 

 

Date:

 

 

 

I confirm on behalf of the provider that the information on this form is correct and, to the best of my knowledge, the above name learner is eligible to enter the specified programme. Where applicable, I have seen evidence to support the residency criteria.

 

Provider Name: YOUTH EDUCARE

 

 

Provider Signature:

Date:

 

 

We are located at:

YOUTH EDUCARE:

Suite 515

Olympic House

28-42 Clements Road

Ilford

IG1 1BA

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