Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Mobile Phone

(###)

###

####

Courses you wish to apply for:

1st Choice

2nd Choice (not compulsory)

Please tell us if you have any disability or learning difficulties. Please tick as appropriate:

Visual impairment

Disability affecting mobility

Social and emotional difficulties

Moderate Learning difficulty

Dyslexia

Autistic spectrum disorder

Temporary disability after illness (e.g. post viral) or accident

Other specific learning difficulty (e.g. dyspraxia, dyscalculia, ADHD)

Other learning difficulty

Hearing impairment

Profound complex disabilities

Mental health difficulty

Severe learning difficulty

Other physical disability

Other medical condition (e.g. epilepsy, asthma, diabetes)

Prefer not say

None

Other (please specify below)

Keeping in touch

For you to stay up to date with your application process or enquiry we will get in touch from time to time to inform you about college events including open days and other events as well as other relevant information such as new courses or services that we intend to provide.

Yes please, I would like to receive communications by email

Yes please, I would like to receive communications by telephone

Yes please, I would like to receive communications by mobile (SMS)

Yes please, I would like to receive communications by pos

No, I would prefer not to be contacted

Date

MM

DD

YYYY