ProudShapes Enrolment Form

ProudShapes Enrolment Form

Fill out the form carefully for registration
Learner’s Name*

First NameMiddle NameLast Name
Date*

DayMonthYear
Date
Gender
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
NI Number
Learner’s E-mail*
example@example.com
Mobile Number*
Emergency Contact Person

First NameRelationship to you
Emergency Contact (next of kin) phone number
Courses you're applying for*
Additional Comments
Ethnicity*

English/Welsh/Scottish/Northern Irish/BritishIrishGypsy or Irish TravellerAny other white backgroundWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other Mixed/multiple ethnic backgroundIndianPakistaniBangladeshiChineseAny other Asian backgroundAfricanCaribbeanAny other Black/African/Caribbean backgroundArabAny other ethnic group
Employment status

In paid employmentIn paid employment – self employedNo in paid employment, looking for work and available to start workNot in paid employment, not looking for work and/or not available to start workIn full-time education or training prior to enrolmentIn full-time education or training prior to enrolmentRetired
If in paid employment:

Less than 16 hours per week16 – 19 hours per week20+ hours per week
Length of employment in current role:

Up to 3 months4 – 6 months7 – 12 months12+ months
If not in paid employment, length of unemployment:

Less than 6 months6 – 11 months12 – 23 months24 – 35 months36+ months
Are you in receipt of:

Universal CreditJob Seekers Allowance (JSA)Employment and Support Allowance – Work Related Activity Group (ESA WRAG)Any other state benefit other than JSA, ESA, WRAG or Universal Credit
Qualifications:

No qualificationsEntry LevelLevel 1 (e.g. 5 x GCSE D-G / 1-3 or fewer than 5 A8-C / 4-9 / BTEC CertGHVQ Foundation (1AS level)Full Level 2 (e.g. 5x GCSE A*- C / 4-9 / BTEC Diploma / GNVQ Intermediate / 2/3 AS Levels / 1 A Level)Full Level 3 (e.g. 2 or more A Levels / 4 AS Levels or BTEC National, ONC / OND / GNVQ Advanced)Full Level 4 (e.g. First Degree, HNC)Full Level 5 (e.g. HND / Other Higher Diploma)Level 6 (e.g. Bachelor Degree / Advanced Diploma)Level 7 (e.g. Postgrad Cert / Diploma, Fellowships / Diploma, Masters Degree)
Do you have a GCSE in Maths?

YesNo
If yes, please state grade achieved:
Do you have a GCSE in English?

YesNo
If yes, please state grade achieved:
Have you taken / will you be taking any qualifications at other institutions during 2018/19 (01/08/18– 31/07/19)?

YesNo
If yes, please specify:
IF YOU HAVE ANY PREVIOUS EXPERIENCE OR RELEVANT QUALIFICATION PLEASE STATE HERE: (overseas, european, UK L2/L3 QUALIFICATION HELD)
Learner's Support

The following questions are aimed at helping put any required support in place and the details can be discussed at the confidential support needs interview.
Do you have a disability, medical condition or health issue?

YesNo
If yes, please indicate:

4 - Visual impairment (not glasses)5 - Hearing impairment6 - Disability affecting mobility7 - Profound / Complex disabilities8 - Social and emotional difficulties9 - Mental health difficulty10 - Moderate learning difficulty11 - Severe learning difficulty12 - Dyslexia13 - Dyscalculia (difficulty with numbers)14 - Autism Spectrum Disorder15 - Asperger’s16 - Temporary Disability after illness17 - Speech, Language and Communication Needs93 - Other physical disability94 - Other specific learning difficulty (ADHD, Dyspraxia, Dysgraphia - writing)95 - Other medical condition (e.g. epilepsy, asthma, diabetes)96 - Other learning difficulty97 - Other (please state below)
Please state your most significant or primary learning difficulty, disability or health problem:
Any other relevant information:
Would you like to discuss your needs with a member of the Additional Learning Support team?

YesNo
Do you have a criminal record?

YesNo
If yes, please give details:
Household Situation (tick all that apply):

No household member is in employmentThe household includes only one adult (aged 18 or above)The household includes one or more dependent childrenI wish to withhold this informationNone of these statements apply
Important Notice

ProudShapes Ltd is registered under the Data Protection ACT 1998 and operates within the eight principles of Data Protection.

How We Use Your Personal Information

The personal information you provide is used for company procedures needs only and wouldn’t be used for any other purposes.
Please tick your preferred method of contact. If no box is ticked, will chose the most appropriate method of communication:*

EmailPhonePost
Please note ProudShapes may contact you if necessary by phone, email, or post about anything to do with your chosen programme of study or other urgent matter.

I agree to comply with ProudShapes Ltd policies and procedures.

I have read, understood, and agree to the terms and conditions shown above.

I also agree that I may request a refund within 14 days of submitting the application form. If the 14-day refund period has expired, I understand that I have the option to select an alternative course.
Initials*
Signature*

Clear
Date*

DayMonthYear
Date
ID DOCUMENT TYPE*
ID DOCUMENT NUMBER*
ATTACHED PHOTO OF: PASSPORT / DRIVING LICENC/ ID CARD*

Cancelof
Signature*

Clear
Take Selfie Photo to confirm your ID*
Date*

DayMonthYear
Date
Should be Empty: