Part Time Course Application 2014/15

Short Courses Office, Plumpton College, Ditchling Road, Plumpton, East Sussex, BN7 3AE
Telephone: 01273 892035 Email: pd@plumpton.ac.uk
Personal Details

Your choice of course(s)

Surname:

Course name 1:

Forename(s):
Date of Birth:

Start date:

Title: Mr/Mrs/Ms/Miss/Other (please state):

Course Code:

Nationality:

Tuition Fee:

Gender:

Registration and Assessment Fee:

National Insurance Number:

Course name 2:

Unique Learner Number (if known)

Start date:

No:

Course Code:
Tuition Fee:

Contact Details

Registration and Asessment Fee:

Address:

Promotional Code:

Prior Attainment

Postcode:

Highest Level of Qualification:

Home Tel:
Mobile Tel:
Email:

Meeting your individual needs

Criminal Record

Do you consider yourself to have a disability?

If so, please specify from the list below:

Yes

Do you have a Criminal Record?

No

If Yes, please call Academic and Quality Manager with details

Tel: 01273 892054

01 Visual impairment
02 Hearing impairment
03 Disability affecting mobility

Residency

04 Other physical disability

Have you been permanently resident in the UK for the past

Yes
No
3 years?
Country of Residency:
If no, please state where you have been living and why:

05 Other medical condition

(for example epilepsy,
asthma, diabetes)
06 Emotional/behavioural
difficulties
07 Mental health difficulty

08 Temporary disability after

illness (for example postviral) or accident
09 Profound complex
disabilities
10 Aspergers Syndrome
90 Multiple disabilities
97 Other
98 No disability
99 Not Known/information
not provided

Are you currently, or could you be pregnant?

If no, please give your Date of Entry to the UK:

If so, please specify from the list below:

British

Pakistani

Any Other White Background

Bangladeshi

Irish

Chinese

Gypsy or Irish Traveller

Any other Asian background

Mixed / Multiple ethnic group

African

White and Black Caribbean

Caribbean

White and Black African

Any other Black / African

/ Caribbean background

Indian

No

Do you consider yourself to have a learning disability?

Ethnic Origin

White and Asian

Yes

Arab
Any Other Ethnic group

01 Moderate
learning difficulty
02 Severe learning difficulty
10 Dyslexia

20 Severe learning difficulty

90 Multiple learning
difficulties
97 Other

11 Dyscalculia

98 No learning difficulty

05 Other specific learning

difficulty

99 Not Known/information not

provided

I give my permission for this information to be passed to those

persons within the college who are involved in providing
Additional support, including Teaching Staff, the Exams Office
and the Learning Support Staff.

Signed:
Date:

How did you find out about the College?

Teacher/Careers Teacher

Payment Details Continued

Employee/Student/
Former Student

Radio

My employer is paying my fees

Purchase Order Number

Exhibition/Show

Newspaper/Magazine

- please invoice my company as follows:

Company name:

Leaflet

Careers Office

Address:

Internet

Careers Fair

Other:

Friend or Relative

Postcode:

Employment Status

Telephone:
Authorising office name:

I am in paid employment
I am self employed
Yes

Is this course relevant to your work?

No

How many hours per week do you work?

Authorised signature:
Date:
Enrolments cannot be processed without a signature.

How long have you been employed?

Employer Details

Plumpton College Discretionary Skills Training Fund

Students aged 19+ on the course start date studying up to Level 2
who are Unemployed, on benefits, looking for work and hope this
course will increase the chance of getting a job OR aged 19-23 on
the course start date studying a Level 3 course.

Name of company:
Address:

I am not paying my own tuition fees for the reason

indicated below:
Postcode:

I am aged 16-18 and therefore may be exempt from paying

tuition fees

I am not in paid employment and am looking for work

I am not in paid employment and I am not looking for work
How long have you been unemployed?

This is my first level: One

Your Payment Details

Three

Council Tax Benefit Letter from relevant council

Employment Support Allowance (WRAG) letter from Benefits Agency
Housing Benefit Letter from relevant council

I am paying my own tuition and / or registration fees as

indicated below:

Income Support Letter from Benefits Agency

Jobseekers Allowance Letter from Benefits Agency

CREDIT / DEBIT CARD

Please complete card details. We take payment then destroy

these details. We accept payment via phone.
(We do not accept American Express)

BANK TRANSFER

Your payment will be required after enrolment. You will then be

sent the college details.

CASH - PAYABLE AT COLLEGE

DIRECT DEBIT

Only available on request.

Type of card: JCB / MAESTRO / VISA / SWITCH

.

Card holders name:

Signature:
Start date:

Two

Attach the relevant evidence of one of the following:

Please choose the option that applies to you / how

you are paying

Amount to Charge

I may be entitled to a tuition fee concession as I am unemployed and

I am in receipt of an income based benefit.

Working Tax Credit from Benefits Agency

Signature
I declare that to the best of my knowledge the information
given above is correct and that if accepted, I agree to comply
with the College rules and regulations. I have read and
understand the college policy on refunds / course cancellation.
I confirm that I have been given sufficient guidance on course
suitability, entry requirements, progression, financial advice and
learning support. I agree to attend regularly and pay any
relevant examination / registration fees. I agree to submit any
required work and enter / sit any required examinations as part
of the course.
Signed (student):

m m

Expiry date:

m m

Issue no (Switch):
Card no:

Security code:

WE DO NOT TAKE PAYMENT UNTIL ENROLMENT

Date:
To be countersigned by parent / guardian if under 18.
Signed (parent / guardian):
Date:
Print name:
Relationship:

How We Use Your Personal Information - The personal information you provide is passed to the Chief Executive of Skills Funding (the Agency)

and, when needed, the Department for Education, including the Education Funding Agency to meet legal responsibilities under the Apprenticeships, Skills, Children
and Learning Act 2009, and for the Agencys Learning Records Service (LRS) to create and maintain a unique leaner number (ULN). The information you provide
may be shared with other organisations for education, training and employment related purposes, including research. Further Information about use of and access to
your personal data and details of organisations with whom we regularly share data are available at: http://skillsfundingagency.bis.gov.uk/privacy.htm. This activity has
been directly or indirectly part-financed by the European Social Fund - helping develop employment by promoting employability, business spirit and equal
oppurtunities and investing in human resources.