Application for a work-based learning course 2011/12

Fields in bold are required

1. Surname
2. Forename(s)
3. Gender

   MaleFemale
4. Date of birth
5. Age on 1/09/2011
6. Nationality
7. Unique Learner Number
8. Address
9. Postcode
10. Telephone No.
11. Mobile
12. Email
13. Current or Last School/College/ Employer
14. Which course or AS level subjects would you like to study?
15. What career would you be interested in on completion of this course?
16. Name of Parent/Guardian (if under 18 on 1st September 2011)

1. I am happy to receive SMS correspondence from Selby College
2. I am happy for my photograph to be used for the purpose of advertising
3. I do not agree to my examination results being published for promotional purposes

1. Subject
2. Level
3. Date
4. Estimated/Actual Grade

1. Subject
2. Level
3. Date
4. Estimated/Actual Grade

1. Subject
2. Level
3. Date
4. Estimated/Actual Grade

1. Subject
2. Level
3. Date
4. Estimated/Actual Grade

1. Subject
2. Level
3. Date
4. Estimated/Actual Grade

1. Subject
2. Level
3. Date
4. Estimated/Actual Grade

1. Subject
2. Level
3. Date
4. Estimated/Actual Grade

1. Subject
2. Level
3. Date
4. Estimated/Actual Grade

1. Subject
2. Level
3. Date
4. Estimated/Actual Grade

1. Subject
2. Level
3. Date
4. Estimated/Actual Grade

1. Subject
2. Level
3. Date
4. Estimated/Actual Grade

1. Subject
2. Level
3. Date
4. Estimated/Actual Grade

1. What interests or hobbies do you have?
2. What work experience have you had?
3. Have you applied or will you be applying to any other schools or colleges for a course in 2011?

   Yes No
4. If so, which one?
5. Which course(s) have you applied for there?

The following information will not affect how we assess your application.

1. Do you consider yourself to have a learning difficulty and/or disability?

   Yes No
2. Have you had any learning support in school?

   Yes No
3. If yes, to either of the above questions, please give details:
4. Do you feel you would benefit from Learning Support? If so please tell us how?

Please indicate all that apply.

1. Social services
2. Youth Justice
3. REOTAS
4. Mental Health Team
5. Foundation Housing
6. Young Carers
7. Family Support Services
8. Other (please state):

1. Briefly state why you wish to be considered for the course. Include details of previous/current employment/courses. If you have relevant examination qualifications please enter these in section A.

Please note: For those applying from school, this should be your Head Teacher, Head of Year or Head of Careers.

1. Name
2. Address
3. Relationship to applicant