Enrolment Form 2015-16
Medway Adult & Community Learning Service
Please ask if you would like help completing this form
Personal Details
Title:
Surname:
Gender: Male/Female
Date of birth:
Address:
Postcode:
Forename:
Learner Number:
Telephone
Home:
Work:
Mobile:
Email Address:
Ethnicity – please tick the option that best describes your ethnic group or background:
White
Mixed/Multiple Ethnic
English/Welsh/Scottish/Northern Irish/British
Irish
Gypsy or Traveller
Any other White background
Asian or Asian British
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background
White and Black Caribbean
White and Black African
White and Asian
Any other mixed background
Black or Black British
African
Caribbean
Any other Black background
Other ethnic groups
Arab
Any other ethnic background
Do you consider yourself to have a learning difficulty, disability or health problem?
Yes
No
If yes, please tick all that apply
1. Visual Impairment
2. Hearing Impairment
3. Disability affecting mobility
4. Profound complex disabilities
5. Temporary disability after illness or
accident
6. Mental health difficulty
7. Other physical disability
8. Other disability
9. Dyslexia
10. Dyscalculia
11. Autism spectrum disorder
12. Asperger’s syndrome
13. Moderate learning difficulty
14. Severe learning difficulty
15. Other medical condition
16. Social & emotional difficulties
17. Other specific learning difficulty
18. Other learning difficulty
19. Prefer not to say
If you have ticked more than one, please put the number of the option that you
consider will most affect your ability to learn?
Surname:
Forename:
Learner No:
Confirmation of residency
Have you been living continuously in the UK for at least the last 3 years?
If no,
Are you an EEA national (or spouse or child of an EEA national) who has
been living continuously in the EEA for at least the last 3 years?
If yes, please specify which country:
If no, please ask for form RES01 before enrolling
Course No
Title
Day &
Time
Yes
No
Yes
No
Fee
For office use only
Receipt CIS
Initials
Directory
Twitter
Tutor
Other
How did you hear about the course?
Website
Press
Leaflet
E-Mail
Word of Mouth
Office Staff
Payment Details (only to be completed if you are paying a fee)
Fee paid in full on enrolment
Fee to be paid by standing order – first instalment to be made at time of enrolment
Fee to be paid by invoice – letter of authority required
Concession Claimed
Jobseekers Allowance
Skills Training Funding
Aged 60+ and not employed for more
than 16 hours per week
Disability Living Allowance/Incapacity
Benefit/Invalid Care Allowance
Employment & Support Allowance (WRAG)
Means Tested Benefit
Unwaged Dependant of person in receipt of
means tested benefit
Other, please specify
PLEASE READ AND SIGN
I confirm that the information given on this form is correct. If fees are due for the course I agree to pay
the fees for the whole course including outstanding instalments if I withdraw. I understand that
refunds are only given when a class is closed. I am aware of the fees and charging policy.
Signature:
Date:
How we use your Personal Information
The personal information you provide is passed to the Chief Executive of Skills Funding (“the Skills Funding Agency”) and the
Department for Business, Innovation and Skills (BIS). Where necessary it is also shared with the Department for Education,
including the Education Funding Agency.
The information is used for the exercise of functions of these government departments and to meet statutory responsibilities,
including under the Apprenticeships, Skills, Children and Learning Act 2009, and to create and maintain a unique learner number
(ULN) and a Personal Learning Record (PLR). The information you provide may be shared with other organisations for education,
training, employment and well-being related purposes, including for research.
You may be contacted after you have completed your programme of learning to establish whether you have entered employment or
gone onto further training.
You can opt out of contact from the SFA by ticking any of the following boxes if you do not wish to be contacted by them.
About courses or learning opportunities
By post
For surveys and research
By phone
By e-mail
Further information about use of and access to your personal data, and details of organisations with whom we regularly share data
are available at
https://www.gov.uk/government/publications/sfa-privacy-notice