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Part-Time Application Form

Personal Details

Title*
Dr
Mr
Mrs
Miss
Ms
Mx
First Name(s)*
Surname*
Current Address*
Postcode*
Date of Birth*
Age on 31/08/17*
Gender*
Home Tel Number
Mobile Tel Number*
Work Tel Number
Email Address*
Next of Kin/Carer Name
Next of Kin/Carer Tel Number
Next of Kin/Carer Email
National Insurance Number (Mandatory for JSA/ESA/Universal Credit)
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Ethnicity and Residency

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)
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)
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Education

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 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
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
Please tick below if any of the following apply
You have an Educational Health & Care Plan (EHCP)
You receive HEFCE Disabled Students Allowance
You are or have been eligible for Free School Meals
You would like to talk to someone about any additional help or support you may need for your course (eg reading, writing or maths)
You are a disabled young person receiving Personal Independence Payments or both Employment and Support Allowance and Disability Living Allowance
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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
Less than 16 hours per week (02)
16-19 hours per week (03)
20 or more hours per week (04)
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 31/08/17 (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 and any legal 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
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 2017/2018
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 the Data Protection Act 1998, 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 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 the Data Protection Act 1998.

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.

Further information about use of and access to your personal data, and details of organisations with whom we regularly share data with are available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/579974/Tier_2_SFA_privacy_notice_13Dec2016.pdf

For reporting purposes we will need to contact you in order to establish your destination data.

We would like to keep you up-to-date with information related to your course and any other exciting news at the College. The changes to personal data law mean you’ll have to give us permission to continue to stay in touch with you. Please select below to make sure you don’t miss out!

I would be interested in receiving (Please tick all that apply):
Information about new courses
Newsletters and upcoming events
Research and surveys
None of the above
I am happy for you to contact me by (Please tick all that apply):
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 the Data Protection Act 1998."""
Yes
No

"I confirm I have read the Learning Agreement Declaration above, am aged 16+ and that I understand the questions I have answered above."

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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