First Name

Last (Family) Name

Address

Postcode

Email Address

Telephone Number

Mobile Number

Date of Birth

Nationality

Please indicate your residency status by ticking one of the following. You will be asked to provide proof of your status when you attend class. Please indicate your residency status by ticking one of the following. You will be asked to provide proof of your status when you attend class. UK / EU Citizen or Dependent Asylum / Temporary Admission / Refugee or Dependent Student Visa or Dependent Work Visa or Dependent Student Visitor Visa Other

If 'Other' please specify.

How long have you lived in the UK (Years/Months)?

Gender Gender Male Female Other

Ethic Origin (Please choose 1) Ethic Origin (Please choose 1)ChineseIndianPakistaniBangladeshiOther AsianCarribeanAfricanOther BlackWhite ScottishWhite IrishWhite WelshWhite EnglishWhite OtherMixedAny other Ethnic Origin

What Languages do you speak?

Have you completed any other ESOL learning? Have you completed any other ESOL learning? I have completed other ESOL Learning I have not completed any other ESOL Learning

If so which levels (mark all that apply) If so which levels (mark all that apply) Pre entry Speaking and listening Entry 1 Reading and Writing Entry 1 Speaking and Listening Entry 2 Reading and Writing Entry 2 Speaking and Listening Entry 3 Reading and Writing Entry 3 Speaking and Listening Level 1 Reading and Writing Level 1 Speaking and Listening Level 2 Reading and Writing Level 2 Speaking and Listening

Where? Where? With Premier Learning With Rotherham College In my home country Other

If 'Other' please specify

Additional Support: Tick the box that best describes your situation Additional Support: Tick the box that best describes your situation Dyslexia/specific learning difficulty Blind or partially sighted Deaf or hard of hearing Mental health difficulty Medical problems e.g diabetes Mobility difficulty/wheelchair user Autistic Spectrum Disorder (Asperger's Syndrome) No additional support needed. Other

Other support needs (Please give details)

We are committed to making reasonable adjustments to enable someone with an additional support need to participate in learning programmes. This could involve providing equipment and/or practical assistance. In order to do this, we need your consent to pass information to appropriate staff who will contact you to discuss support. If you do not consent, any reasonable adjustments which could be made, may not be possible. I consent to this information being used to make necessary reasonable adjustments. Signature * We are committed to making reasonable adjustments to enable someone with an additional support need to participate in learning programmes. This could involve providing equipment and/or practical assistance. In order to do this, we need your consent to pass information to appropriate staff who will contact you to discuss support. If you do not consent, any reasonable adjustments which could be made, may not be possible. I consent to this information being used to make necessary reasonable adjustments. Signature * By ticking this box I consent to the above By ticking this box I DO NOT consent and I understand you may not be able to progress my application.

Are there any Health Issues we should know about? Are there any Health Issues we should know about? Yes No

Please specify Please specify Epilepsy Diabetes Asthma High blood pressure Other

If 'Other' please specify

Are you in the vulnerable or extremely vulnerable category? Are you in the vulnerable or extremely vulnerable category? Yes No

Any Additional Information you wish to provide to support your application?

I agree to Premier Learning processing personal data contained in this form, or other data which the organisation may obtain from myself or other people during the application process and whilst I am a student. I agree to the processing of such data for any purposes connected with my studies, my health and safety or for any other legitimate reason. Declaration I confirm that, to the best of my knowledge, the information given is correct and complete. I agree to Premier Learning processing personal data contained in this form, or other data which the organisation may obtain from myself or other people during the application process and whilst I am a student. I agree to the processing of such data for any purposes connected with my studies, my health and safety or for any other legitimate reason. Declaration I confirm that, to the best of my knowledge, the information given is correct and complete. By ticking this box I agree to the above I don't agree. By ticking this box I understand that you may not be able to progress my application.