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Part-Time Application Form

Personal Details

Title*
Dr
Mr
Mrs
Miss
Ms
Mx
First Name(s)*
Surname*
Date of Birth*
Age on 31/08/19*
Gender*
Current Address*
Postcode*
Home Tel Number
Mobile Tel Number*
Work Tel Number
Email Address*
National Insurance Number (Mandatory for JSA/ESA/Universal Credit)
Next of Kin/Carer Name
Next of Kin/Carer Tel Number
Next of Kin/Carer Email
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Ethnicity and Residency

Nationality*
Country of Domicile: (Where normally resident)*
Have you lived in the UK or the European Economic Area (EEA) for the last 3 years?*
Yes
No
Please state which country you lived in previously
Date of entry into UK (Please note: you will be required to provide evidence of residency status)
Tick one box which best describes your ethnic origin: *
English/Welsh/Scottish/Northern Irish/British (31)
Irish (32)
Gypsy or Irish Traveller (33)
Any Other White Background (34)
White and Black Caribbean (35)
White and Black African (36)
White and Asian (37)
Any Other Mixed/Multiple Ethnic Background (38)
Indian (39)
Pakistani (40)
Bangladeshi (41)
Chinese (42)
Any Other Asian Background (43)
African (44)
Caribbean (45)
Any Other Black/African/Caribbean Background (46)
Arab (47)
Any Other Ethnic Group (98)
Do not wish to declare (99)
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Section 3: Education (Not required for non-qualification courses)

Highest level qualification you have attained to date (documentary evidence will be required)*
Entry Level (9)
Other Qualification Level (Below Level 1) (7)
Level 1 (1)
Full Level 2 (2) eg 5 GCSEs 9-4 (A*-C) or equivalent
Full Level 3 (3) eg 4 AS levels, 2 A Levels or equivalent
Level 4 (10) eg NVQ Level 4/HNC/Certificate of Higher Education
Level 5 (11) eg HND/Foundation Degree/Diploma of Higher Education
Level 6 (12) Degree or equivalent
Level 7 and above (13) Postgraduate/Masters/Doctorate
Other Qualification Level Not Known (97)
No Qualification (99)
GCSE English grade
Year achieved
GCSE Maths grade
Year achieved
Name of last school and/or college attended: (Optional for 24+)
Are you currently enrolled on a Qualification course at another institution?*
Yes
No
Please provide details
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Disabilities, Medical Conditions & Learning Support Details

Please indicate below if you have a learning difficulty, disability, health issue or medical condition.

Do you think you have a learning difficulty and need support with your learning?*
Yes
No
Please tick below which applies to you
Autism Spectrum Disorder (14)
Dyscalculia (13)
Dyslexia (12)
Mild/Moderate Learning Difficulty (10)
Severe Learning Difficulty (11)
Speech, Language & Communications Needs (17)
Other Specific Learning Difficulty (94/96) Please provide details: eg Dyspraxia
Please tick below if you have an Education Health & Care Plan (EHCP)
Yes
No
Do you think you have a disability or medical condition?*
Yes
No
Prefer not to say (98)
Please tick below which applies to you
ADD/ADHD (95)
Aspergers Syndrome (15)
Asthma (95)
Diabetes (95)
Disability Affecting Mobility (06)
Epilepsy (95)
Hearing Impairment (05)
Mental Health Difficulty (09)
Other Physical Disability (93)
Profound Complex Disabilities (07)
Social & Emotional Difficulties (08)
Temporary Disability After Illness or Accident (16)
Visual Impairment (04)
Other Disability (97) Please provide details:
If you have ticked more than one box, please state main condition
Do you think you require support or adaptations in College?*
Yes
No
Please specify any prescribed medication you are taking
Please list any allergies relevant to your proposed course
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Employment Status

Are you employed?*
Yes, in Paid Employment (10)
Yes, Self Employed (1)
No, Not in Paid Employment (11)
Please tick the relevant number of hours you work
0 - 10 hours per week (05)
11 - 20 hours per week (06)
21 - 30 hours per week (07)
30 or more hours per week (08)
How long have you been employed in your current job?
Less than 3 months (01)
4 - 6 months (02)
7 - 12 months (03)
More than 12 months (04)
Please tick the relevant boxes
Not in paid employment, looking for work and available to start work (11)
Not in paid employment, not looking for work and/or not available to start work (12)
How long have you been unemployed?
Less than 6 Months (01)
6 - 11 Months (02)
12 - 23 Months (03)
24 - 35 Months (04)
More than 36 months (05)
Please tick which of the following statements 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 the household
None of these statements apply
I confirm that I wish to withhold this information
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Declaration of Criminal Convictions

Please disclose all unspent convictions for any offence. (You do not have to disclose any convictions that are spent, including any cautions, reprimands or final warnings unless they are relevant†.)

Do you have any unspent criminal convictions?*
Yes
No
Do you have any relevant† criminal convictions? *
Yes
No
Do you have any serious criminal charges awaiting trial?*
Yes
No

As a duty of care to staff and students, the College reserves the right not to enrol a person where there is evidence that they could be a threat or danger to others. Declaring convictions may not prevent you from being offered a place but failure to disclose something of which we later become aware could result in disciplinary action or your enrolment being cancelled.

†Relevant means offences against a person, whether of violent or sexual nature and convictions involving unlawful supplying of or possession of controlled drugs or substances.

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Course Details

Please state which course(s) you wish to enrol on (including course codes if known)

Course Code
Course Title*
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Payment of Fees

Please complete one of the following sections, whichever is relevant to you. If section C applies, evidence must be provided at enrolment to confirm a fee concession

A. Fees are payable and I am not entitled to a fee waiver
I am paying the tuition fees directly in full (NOWAIVER)
I have completed an instalment agreement (only applicable where tuition fees are more than £400) (NOWINST)
My employer or sponsor is paying my tuition fees (a completed Employer Sponsor Form is required) (NOWEMP)
I have applied to the Student Loans Company for a Tuition Fee Loan (NOWLOAN)
I have applied to the Student Loans Company for an Advanced Learner Loan (NOWLOAN)
Total Fees Payable
B. No payment is required as
I am aged 16-18 as at 31/08/19 (NOW1618)
There are no fees attached to the course (NOWFEES)
I am under 25 years old, have an EHCP and have not yet completed the learning outcomes identified (NOWU25)
C. I am entitled to a fee waiver as
I am in receipt of Job Seekers Allowance (WAVJSA)
I am in receipt of Employment and Support Allowance – Work Related Activity Group (WAVESA)
I am in receipt of Universal Credit and I am mandated to undertake skills training (WAVUCR)
I am in receipt of a means-tested benefit (first leisure course funded) (WAVBEN)
I am unemployed/working less than 16 hours per week AND in receipt of a means-tested state benefit and believe that skills training ie this programme of study will help me enter employment (WAVUNEM)
I am 19-23 years of age and eligible for a full Level 2 waiver, studying my first and full Level 2 Qualification OR need a step-up from basic skills in order to progress to a full Level 2 (WAVFL2)
I am 19-23 years of age and eligible for a full Level 3 waiver; I have not yet attained a full Level 3 Qualification and intend to study for my first and full Level 3 (WAVFL3)
Benefit type
D. I am an apprentice and
I am aged 16-18 at the start of my apprenticeship (APP1618)
I am aged 19 or over at the start of my apprenticeship (APPADULT)

FEE DECLARATION
I am satisfied that the costs associated with the programme have been explained to me. If any proposed payment via a loan or employer is not fulfilled, or I withdraw, the liability for any unpaid fees will revert back to me. In the event that a debt collection agency is involved then I will be liable for tuition fees plus any legal and administrative fees incurred. I understand that refunds will only be issued in the event of the course being cancelled by the College or in exceptional circumstances in line with the College Refund Procedure (copy available on request).

I confirm that I have read and agreed the above declaration
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Marketing Evaluation

Are you a current East Surrey College student?*
Yes
No
Where have you seen marketing promotions for your course/ESC? (Please tick all that apply) *
Billboard
Bus Stop/Tram Advert
College Open Event
Course Guide
Email
Employer
Facebook/Instagram
Family/Friend
Former/Current Student
Hotcourses/Floodlight
Job Centre Plus
Leaflet
LinkedIn
Press Advert
School/College
Search Engine (ie Google)
Text Message
Twitter
UCAS
Website
Other:
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Imagery

On occasion you may be photographed/filmed in your classroom, around the College or at an event. Your image and your name may be used to celebrate student success or to promote courses and events.

I give my permission for East Surrey College to publish my image and/or name in any printed and/or electronic promotional materials. The College will not utilise my personal data in a defamatory manner and shall keep it secure throughout the period of its use. I understand that I can withdraw my permission at any time although I am aware any such published material will not be recalled if I choose to withdraw my consent.
Yes
No
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Learning Agreement Declaration

I am satisfied that:
- The suitability of the programme and the entry requirements for it have been explained to me.
- I have received information, advice and guidance on my choice of learning programme and progression routes.

Declaration:
- I formally accept the learning programme specified on this agreement.
- I certify that the information I have provided is complete and correct.
- I agree to abide by the College regulations and the East Surrey College Charter (available at www.esc.ac.uk).
- I authorise the College to provide appropriate information to my parent(s) or guardian(s) (if under 19) or employer, sponsor or Student Loan Company (if appropriate) on progress and attendance on courses for which I have enrolled, or in the event of any cause for concern or a medical emergency.

Privacy Statement
This privacy notice is issued by the Education and Skills Funding Agency (ESFA), on behalf of the Secretary of State for the Department of Education (DfE). It is to inform learners how their personal information will be used by the DfE, the ESFA (an executive agency of the DfE) and any successor bodies to these organisations. For the purposes of relevant data protection legislation, the DfE is the data controller for personal data processed by the ESFA.
Your personal information is used by the DfE to exercise its functions and to meet its statutory responsibilities, including under the Apprenticeships, Skills, Children and Learning Act 2009 and to create and maintain a unique learner number (ULN) and a personal learning record (PLR). Your information will be securely destroyed after it is no longer required for these purposes.
Your information may be shared with third parties for education, training, employment and well-being related purposes, including for research. This will only take place where the law allows it and the sharing is in compliance with data protection legislation.
The English European Social Fund (ESF) Managing Authority (or agents acting on its behalf) may contact you in order for them to carry out research and evaluation to inform the effectiveness of training. You can agree to be contacted for other purposes by ticking any of the following boxes:

For surveys and research
About courses or learning opportunities
By Post
By Email
By Phone

Further information about use of and access to your personal data, details of organisations with whom we regularly share data, information about how long we retain your data, and how to change your consent to being contacted, please visit: www.gov.uk/government/publications/esfa-privacy-notice
For reporting purposes we will need to contact you in order to establish your destination data.

Your privacy is important to us. We’d like to keep in touch so please complete your contact preferences below. (Please tick all that apply):

I would be interested in receiving:*
Information about new courses
Newsletters and upcoming events
Research and surveys
None of the above
I am happy for you to contact me by:
Email
Post
Telephone
SMS (Text)
I declare that to the best of my knowledge the information I have given is a true and correct record and I give my consent to East Surrey College processing this information in accordance with GDPR and the Data Protection Act 2018.*
Yes
No

"I confirm that I have read the Learning Agreement Declaration incorporating the Imagery and Staying In Touch sections."

Please click Submit to confirm the above statement.

You can withdraw your permission for the use of your personal data at any time by contacting Client Services at clientservices@esc.ac.uk. (If you would like a more detailed explanation about changes to General Data Protection Regulations and the right to be forgotten visit https://ico.org.uk)

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Address: East Surrey College, Gatton Point, London Road, Redhill, Surrey RH1 2JX

Main Switchboard: 01737 772611 / Client Services: 01737 788444 / Email: clientservices@esc.ac.uk

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