Next of Kin Information Emergency contact name: Relationship: Mobile telephone no: Home telephone no: Disability, Learning Difficulty and or Health Problem – please tick all that apply, if no option is indicated the starred * option will be selected Do you consider that you have a learning difficulty, disability or health problem? Yes *No Other Please specify: Allergy Dyslexia Profound/Complex Disabilities Asperger’s Syndrome Epilepsy Severe Learning Difficulty Asthma Hearing Impairment Social, Emotional & Behavioural Difficulties Autism Spectrum Condition Diagnosed mental health Speech, Language and Communication needs Cystic Fibrosis condition Temporary Disability after Illness or accident Diabetes Moderate Learning Difficulty Visual Impairment (excluding glasses/contact Disability Affecting Mobility Physical Disability lenses) Dyscalculia Other Specific Learning Prefer not to say Difficulty e.g. Dyspraxia Are you a wheelchair user? If you have ticked more than one of the above, please state which disability, learning difficulty and/or health problem impacts most on your learning If you have a support need and would benefit from a confidential interview, please tick this box Do you have an EHCP/Moving on Plan: Yes No Are you or have you been a Looked-After Child (LAC)/Care Leaver as defined in the Children Act 1989 as one who is or has been in the care of, or provided with accommodation by, an English local authority Yes No Prefer not to say Do you intend to study a full-time course at another institution at the same time as this course? Yes No Course Information Start Tuition No of Course Code Day Date fee £ Wks * End Assess No of Course Title Time Date fee £ Hrs/Wk* Total to GLH/ Campus/Venue/ Postcode of Study pay £ Year* Start Tuition No of Course Code Day fee £ Wks * Date End Assess No of Course Title Time Date fee £ Hrs/Wk* Total to GLH/ Campus/Venue/ Postcode of Study pay £ Year* Leading to the following Qualification Aim (Only for ESOL & Functional Skills) *office use only BKSB Expected Office use only BKSB E1 BKSB E2 BKSB E3 BKSB L2 Start Date Total GLH L1 End Date Unregulated ESOL Speaking & Listening Reading Writing Functional Skills English Functional Skills Maths English Unit(s) Maths Unit(s)
Next of Kin Information Emergency contact name: Relationship: Mobile telephone no: Home telephone no: Disability, Learning Difficulty and or Health Problem – please tick all that apply, if no option is indicated the starred * option will be selected Do you consider that you have a learning difficulty, disability or health problem? Yes *No Other Please specify: Allergy Asperger’s Syndrome Asthma Autism Spectrum Condition Cystic Fibrosis Diabetes Disability Affecting Mobility Dyscalculia Dyslexia Epilepsy Hearing Impairment Diagnosed mental health condition Moderate Learning Difficulty Physical Disability Other Specific Learning Difficulty e.g. Dyspraxia Profound/Complex Disabilities Severe Learning Difficulty Social, Emotional & Behavioural Difficulties Speech, Language and Communication needs Temporary Disability after Illness or accident Visual Impairment (excluding glasses/contact lenses) Prefer not to say Are you a wheelchair user? If you have ticked more than one of the above, please state which disability, learning difficulty and/or health problem impacts most on your learning If you have a support need and would benefit from a confidential interview, please tick this box Do you have an EHCP/Moving on Plan: Yes No Are you or have you been a Looked-After Child (LAC)/Care Leaver as defined in the Children Act 1989 as one who is or has been in the care of, or provided with accommodation by, an English local authority Yes No Prefer not to say Do you intend to study a full-time course at another institution at the same time as this course? Yes No Course Information Course Code Day Start Date Tuition fee £ No of Wks * Course Title Time End Date Assess fee £ No of Hrs/Wk* Campus/Venue/ Postcode of Study Total to pay £ GLH/ Year* Course Code Day Start Date Tuition fee £ No of Wks * Course Title Time End Date Assess fee £ No of Hrs/Wk* Campus/Venue/ Postcode of Study Total to pay £ GLH/ Year* Leading to the following Qualification Aim (Only for ESOL & Functional Skills) *office use only Office use only BKSB E1 BKSB E2 BKSB E3 BKSB L1 BKSB L2 Start Date Expected End Date Total GLH Unregulated ESOL Speaking & Listening Reading Writing Functional Skills English Functional Skills Maths English Unit(s) Maths Unit(s)
HE-PT-Enrolment.docx