Faculty of Development and Society
2011/2 APPLICATION FORM - BA Honours Early Years Route
__________________________________________________________________________________________________
Surname
Title: [Please delete)
First Name(s)
 Male
Mr/Ms/Miss/Mrs
 Female
Permanent Address (including post code)
(complete below in BLOCK CAPITALS)
: Home [include code]
: Work [include code]
: Fax [include code]
: Mobile
E-mail address:
(please print clearly)
I agree to allow my email address
to be communicated to fellow students
Date of Birth:
DISABILITIES AND SUPPORT NEEDS
[Please give details below]
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Type of Disability
Dyslexia
Blind/partially sighted
Deaf/Hearing impairment
Wheelchair user/mobility difficulty
Autistic spectrum disorder/Asperser syndrome
Mental health difficulty
Multiple Difficulties
Personal Care Support
'Hidden disabilities' (diabetes, epilepsy, asthma)
Other
Please specify
Please specify
NATURE OF SUPPORT REQUIRED
QUALIFICATIONS [dates and grades of qualifications and awarding body]
Please include details of GCSE, degree and any professional qualifications
Please note you will be required to produce copies of your certificates upon enrolment of the course
Qualification
Subject
Awarding
Institution
(e.g. School/College)
GCSE/GCSE Equivalent
Grade
Date
(Month and Year
completed)
Mathematics
(Please state if Equivalent Qualification)
GCSE/GCSE Equivalent
English Language
(Please state if Equivalent Qualification)
GCSE/GCSE Equivalent
English Literature
(Please state if Equivalent Qualification)
Degree
Please list any other relevant qualifications
NATIONALITY
Country of birth
(the country where you were born)
2
Nationality
(the country for which you are entitled to hold a passport)
Country of domicile
(the country you live in)
Do you require a visa to study in the UK?
Yes / No
If you have a current visa to study in the UK
please give the date of expiry.
ETHNIC ORIGIN
White
Black or Black British - Caribbean
Black or Black British - African
Other Black Background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Other Asian Background
Chinese
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Other Mixed Background
Other Ethnic Background
Prefer not to say
RELIGION
CRIMINAL CONVICTIONS
Do you have any relevant criminal convictions?
Yes / No
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PRESENT EMPLOYMENT [dates and times of employing institutions]
Occupation
Date Started
Employer
Address
Please include a brief outline of your main responsibilities:
RECENT EMPLOYMENT [dates and times of employing institutions]
Occupation
Dates
Employer
Please explain why you wish to undertake this programme of study
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REFERENCE 1
Name Of Prospective Student
Referee's Details
Name
Position
Company/Organisation
Address
Postcode
Country
E-Mail Address
Telephone Number
Fax Number
How Long have you known the candidate?
In What capacity do you know the candidate?
In your opinion is the applicant likely to successfully complete and benefit from the programme of
study for which s/he is applying
 Yes
 No
 Uncertain/don't know
Please explain your response to the previous question and add any further comments
Referee's Declaration
I confirm that, to the best of my knowledge, the information given in this form is correct and complete
Referee's Signature
Date
Official Institutional Stamp
(if appropriate)
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REFERENCE 2
Name Of Prospective Student
Referee's Details
Name
Position
Company/Organisation
Address
Postcode
Country
E-Mail Address
Telephone Number
Fax Number
How Long have you known the candidate?
In What capacity do you know the candidate?
In your opinion is the applicant likely to successfully complete and benefit from the programme of
study for which s/he is applying
 Yes
 No
 Uncertain/don't know
Please explain your response to the previous question and add any further comments
Referee's Declaration
I confirm that, to the best of my knowledge, the information given in this form is correct and complete
Referee's Signature
Date
Official Institutional Stamp
(if appropriate)
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MARKETING INFORMATION
The section below is to help us understand and learn from our marketing strategy. The information
you provide will be used anonymously and be used solely for future marketing strategies.
Please tick which of the following you have made use of when searching for and applying for the BA
(Hons) Early Years Programme
Please tick all that apply 

Local Authority

A Non-SHU Careers Advisor

SHU EYPS Information event

Information Leaflet

Other SHU Information event

SHU Website

Advert in Newspaper/Magazine

Other
Please specify ……………………………………………………………………………………….
Signature of applicant ......................................................................... Date.........................
Please send your application to:
Mr Stephen Coates
Faculty of Development and Society
Sheffield Hallam University
10101 Arundel Building
122 Charles Street
Sheffield
S1 2NE
Tel: 0114 225 5352
Email: s.a.coates@shu.ac.uk
(Please note we will require a hard copy of your application)
Application to the course is subject to the University's Terms and Conditions.
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