STEPNEY GREEN SIXTH FORM I n P u r s u i t o f E x c e l l e n c e

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1 STEPNEY GREEN SIXTH FORM I n P u r s u i t o f E x c e l l e n c e For Admissions Office Use: App. Date Ent. Query Offer Int. Date Int. Date 2 Follow up No Offer Application Form Please complete the form in BLOCK CAPITALS and in ink. Please return completed application and reference form to: Miss Smyth, Stepney Green Sixth Form, Ben Johnson Road, London E1 4SD. Section 1 Your personal details Please enter your name as it appears on official documents: Male Female Date of Birth Surname First Name(s) National Insurance no. Roll no. (Stepney Green students only) Address Contact no. Mobile no. Postcode address Parent/Guardian/Next of Kin Name Relationship Contact no Address (if different from student) address Section 2 The courses you are applying for Subject choices A B C D E A Level BTEC Level 3 Biology Chemistry Maths Maths Further Maths Computing Physics History Fine Art Economics Graphics Sports Science Science (s) Science (d) Sport (s) Sport (d) English GCSE Business (s) Business (d) ICT (d) ICT (s) Maths GCSE * Please choose one subject from each option block (A, B, C & D). If applicable, choose an option in block E (grades in either English or Mathematics are C or below). A. Subject A Levels (AS) BTEC Level 3 (please tick) Notes B. C. D. E. English GCSE E. Mathematics GCSE Important information: Application form submission no later than: Wednesday 29 th January You will find full details of all courses in the prospectus. 2 The course

2 Section 3 Additional support Stepney Green Sixth Form College has a range of additional support. We welcome students with disabilities and health problems. Please mark the boxes that are appropriate to you. This will not affect your application but is to enable us to consider your additional support needs. Disability Health Learning Difficulty Section 2 The ces No disability No health problems No learning difficulty Visual impairment Emotional/behavioral difficulties Moderate learning difficulty Hearing impairment Mental health difficulty Severe learning difficulty Disability affecting mobility Profound complex disabilities Dyslexia A disability or special need not listed Aspergers syndrome Dyscalculia Please state below Multiple disabilities Other specific learning difficulty Temporary disability after illness Autistic spectrum disorder (e.g. post-viral) or accident Multiple learning difficulties I do not wish to give this information Other Other. Please state below I do not wish to give this information Please help us focus sixth form support and services by answering the following questions: Are you living in the care of social services, leaving care services or living in any type of hostel accommodation? Did you receive free school meals in ? Yes Yes No No If you did receive free school meals please tell us the start and end dates: From To Section 4 Equal opportunities We are committed to equal opportunities. Please tick the box which best describes your ethnicity: Asian/Asian British Mixed/multi ethnic group White Indian White and Black Caribbean English/Welsh/Scottish/Northern Irish/British Pakistani White and Black African Irish Bangladeshi White and Asian Gypsy or Irish Traveller Chinese Any other mixed/multiple Any other White background Any other Asian background Ethnic background Black/African/Caribbean/Black British African Caribbean Any other Black/African/Caribbean background Other ethnic group Arab Any other ethnic group Please state below Section 5 Residency Nationality: (as on passport) Date of arrival in the UK: Passport copy included: (if you are not British or are not from an EU or EEU country) Yes No Have you lived in the UK or the European Economic Area (EEA) for the last 3 years? Yes No Section 6 How did you hear about Stepney Green Sixth Form? Internet Website Newspapers Word of Mouth Other

3 Section 7 Education and qualifications Name and address of the school/college you were attending in 2013/2014 Please list any qualifications you have or expect to obtain: Subject Level Predicted grade Actual grade Tutor signature All external candidates should enclose certified copies of their certificates/qualifications with their application Section 8 Tell us about yourself Tell us why you want to do this course, what skills and experience you have that may be useful when studying this course? (e.g. part-time, voluntary work, other courses you have taken). What do you plan to do when you finish this course? What are your career plans? Please continue on a separate sheet of paper if necessary. I hereby agree to abide by the Learning Agreement and the provisions set out in the notes below: Course advice, guidance and fees I confirm that I have completed a pre-entry process with Stepney Green Sixth Form whereby I received appropriate advice, guidance and support to help me choose my programme. I fully understand the entry requirements, suitability and progression opportunities (where applicable) I understand and accept that the sixth form reserves the right to close or combine one class with another. Data Protection I understand that if I request a letter from the sixth form confirming my status as a student my address may be in the letter. I declare that I understand the information I have entered is correct and I understand that this information will be used by Stepney Green Maths, Computing and Science College and Sixth Form staff for enrolment and reporting purposes and that some information requested will be stored on computer. Signature of applicant: Date: Staff name (print): Date: PLEASE NOTE: We require a reference for any applicant aged Please send this completed application form to your school or other appropriate referee (not friend or family). Your application may not be considered until the reference form has been completed.

4 Section 10 Reference Form a. Referee s details Name Position Organisation address Contact no. 1b. Applicant details Name Date of birth 2. Suitability for the programme Please tick the suitability of the applicant to undertake to course shown. Attendance Punctuality Behavior Motivation Oral communication Written communication Academic ability Ability to work on own initiative Attitude to School/College/Work environment Relationships with peer groups and teachers Ability to work as a member of a team Has the applicant ever been excluded or suspended? Yes No 5. Please use this space to make any comments Organisation official stamp: Signed: Date:

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