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PRIVATE & CONFIDENTIAL

Course application form


All applicants must complete this form as fully as possible and return it to
Recruitment Manager: Denise.johnson@michaeljohnacademy.com
0151 708 8558

Unique Learners Identification (ULN)


Office use only
We will process the information provided in line with the Data Protection
Act 1998

Course
Applied for
Personal Details

Learner name must match the birth

(Please complete the form in Black ink)

certificate/passport
*Please state any previous surnames/names you have been known by*

Surname
Forename(s)
Address

Mr / Mrs / Ms / Miss

Postcode
How long have you lived at this address?
Email Address
Contact
Landline:
Mobile:
Number
Date of Birth
Age:
National Insurance Number:
Gender
Male
Female
Please give details of an emergency contact:
Contact
Name
Number:
Relationship

Employment / Work Experience


Are you currently employed?
If Yes, is your Job?

Full Time

Yes

No
Part time

Employer name

How long have you been in the


job role?
How many hours do you work?
Contact
number

Address
Postcode
Employers email
address

Number of employees:

IF NO, are you in receipt of any JSA

Previous
Employm
ent

Employer

ESA/WRAG
Universal Credits
Dates From / To

Other State Benefits

IF NO - Where you in full time education or training prior to enrolment?


Yes
No
IF NO Were you looking for work?

Position Held

Yes

No

Education and Qualifications*If evidence is present on the PLR then there is no need to
complete the Qualifications box*

Do you hold any previous qualifications?

Yes No (For Example, GCSES, NVQ, HNC, GNVQ


ADVANCED, A LEVELS etc.)
If Yes, Please list all qualifications held you must state all academic qualifications gained at school,
college, university and vocational qualifications gained to date. Please note that these details are checked
against the National Record Services and, if incorrect, they may affect your funding for this programme.
School / College

Version 2 (12/10/15)

Qualification
Grade/Level

Qualifications
Grade/Level

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Date Achieved

PRIVATE & CONFIDENTIAL


Course application form
Do you intend to return to school / 6th form?

Yes

*Please remember to bring all of your certificates to your Induction*

Are there any resources that you would need to support your induction? (i.e. enlarged font /coloured
Yes
No - Please specify
paper

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No

PRIVATE & CONFIDENTIAL


Course application form
Nationality
Please state your nationality (e.g. British, Polish)
Have you always been a permanent resident in the
UK?

Yes

No

Ethnic Origin Please tick


32
33
34
35
36

English/Welsh/Scottish/Northern
Irish/ British
Irish
Gypsy or Irish Traveller
Any other white background
White and Black Caribbean
White and Black African

37

White and Asian

31

38
39

40

Pakistani

41
42
43
44
45

Bangladeshi
Chinese
Any other Asian background
African
Caribbean
Any other Black / African / Caribbean
background

46

Any other mixed / multiple ethnic


background
Indian

47

Arab

98
99

Any other ethnic group


Not provided

Do you have any learning difficulties? Please tick


10
11

Moderate learning difficulty


Severe learning difficulty

15
3

12

Dyslexia

94

13
14

Dyscalculia
Autism spectrum disorder

96
NO

Aspersers syndrome
Multiple learning difficulty
Other specific learning difficulty (e.g.
Dyspraxia)
Other learning difficulty
No learning difficulty

Other (please
specify)

Do you have any disabilities / health problems? Please tick


1

Emotional / Behavioural Difficulties

Multiple disabilities

16

Mental Health Difficulties (include stress at


home, work, school)
Temporary disability after illness (e.g. Post-

Visual impairment

93

Other physical disability

Hearing impairment

95

Disability affecting mobility(include


back/neck pain or disorder

97

7
8

Profound complex difficulties


Social and emotional difficulties

(include Colour

Blindness)

Other (please specify)

viral or accident)

98
99
NO

Other medical condition (ie. Epilepsy,


Asthma, Diabetes, Heart disease)
Other disability (e.g. Allergic conditions,
Skin disorders, Eczema, Dermatitis,
Migraine etc.
Prefer not to say
Not provided
No disability

Are there any special requirements we need to take into account to


help support you on the course due to your ethnicity, sexuality or
religious background?
If yes, please specify:

Yes

No

How did you hear about Michael


John Academy?
DECLARATION
TO BE READ AND SIGNED BY THE LEARNER I certify that all the information I have
provided on this application form is true and complete. I understand that providing any
misinformation causing any inaccuracy may have implications to the funding I receive, which
may apply at any time after it is discovered.
Learner Signature:
Date:
Version 2 (12/10/15)

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PRIVATE & CONFIDENTIAL


Course application form
(Office use only)
Potential Programme Identified (Please specify)

Version 2 (12/10/15)

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