Strode College - Full-Time Application Form

First Name(s) (exactly as on official certificate)*
Last Name (exactly as on official certificate)*
Want to be known as
Home Address Line 1*
Home Address Line 2*
Town/City*
County*
Postcode*
Is this address a temporary address?*	Yes No
Gender*	Male Female
Date of Birth (dd/mm/yyyy)*	/ /
Age on 31^st August 2012*
Title*
National Insurance number*
Unique Learner Number (if known)
Contact Details
Home phone (inc code)*
Mobile phone*
Home Email address*
Twittter ID
Skype ID

Asian or Asian British	Indian Pakistani Bangladeshi Chinese Other Asian background
Black or Black British	White and Black Caribbean White and Black African White and Asian Any other mixed background
Black	African Caribbean Any other Black/African/Caribbean background
White	White/Welsh/Scottish/Northern Irish/British Irish Gypsy or Irish Traveller Other White background
	Other ethnic group - Arab Any other ethnic group

A Level subjects
Write a few words to tell us why have you chosen these courses/subjects?
Are you interested in joining the Strode College Aspire Programme?*	Yes No

Name of current or last School or College
Have you had a period of study out of school?	Yes No
Are you currently a student at Strode College?	Yes No
Are you currently attending a programme at college while still at school?	Yes No
Hobbies and Interests
Please write a few words about your hobbies and interests or part-time job.

Do you consider yourself to have a learning difficulty, disability and/or health problem that may affect your learning?*	Yes No
Disability*	No disability Not known Visual impairment Hearing impairment Mobility disability Other physical disability Other medical conditions (epilepsy, asthma, diabetes) Emotional/behavioural difficulties Mental health difficulty Temporary disability after illness or accident Profound Complex Difficulties Aspergers Syndrome Multiple Disabilities Other (describe)
Learning Difficulty*	No learning difficulty Moderate learning difficulty Severe learning difficulty Dyslexia Dyscalculia Other specific learning difficulty Autism Spectrum Disorder Multiple Learning Difficulties Other
My support requirements have already been assessed	Yes No
If you have been formally assessed for an identified learning need/disability, please attach the relevant report.

Full-Time Application Form

Nationality*
Where have you lived for the majority of the last 3 years?*
If you have not been resident in the European Union for the past three years, please give date of entry to European Union

Course Title and Code (first choice)*
Course Title and code (second choice)*

	Please enter Subject, Level (eg GCSE), Predicted grade
Subject 1*
Subject 2
Subject 3
Subject 4
Subject 5
Subject 6
Subject 7
Subject 8
Subject 9
Subject 10
Subject 11
Subject 12

Do you require a bus ticket application form?*	Yes No
If yes, where is your nearest bus stop?
Do you have any special transport requirements?*	Yes No
If yes, tick which you need	Special bus equipment Bus Buddy
Other assistance (details)

Choice 1
Choice 2
Choice 3
If you are interested in a Development Squad, please indicate which one	Football Netball Trampolining

Name of one person we can share data with
Contact phone
Contact email