The School of Health and Human Sciences
Application for admission to study
BSc (Hons) Physiotherapy (pre-registration)
Period of study to begin September 2016
For Office Use Only
For Office Use Only
Application Received (date) ……………………
(Photo)
References Received (1) …………………………
(2) …………………………
Degree Certificate (tick)

Application
forms will be processed in…………………………….
order of receipt – it is in your interest to return this form promptly.
PG number
You must complete all sections of this form as requested. Failure to do so may result in your application
being rejected
1. Surname/Family name (in BLOCK capitals) ………………………………………………………………
2. Forenames in full…………………………………………………………………………….
3. Former Surname ……………………………………………………………………………..
4. Title (Mr/Mrs/Miss/Ms/Dr) ……………………………….
5. Date of birth ......................................................................
6. Male/Female ........................…................…….……..........
7. Contact address & Postal Code………………………………………………………………………………
………………………………………………………………………………………………………………
……………………………………………………………..Post Code………………………….
8. Contact Telephone No. ..................................……………………..
9. Mobile No…………………………………………….
10. E-mail address...............................................................
11a. Nationality ............................................................…...........
11b. National Insurance Number ……………………………..
11c. What is your first language? ………………………....
12. Country of birth .......................................……….……….....
[Places are funded by Health Education East of England, consequently the course is only available to applicants
classified as ‘home’ or ‘EU’ students for tuition fee purposes. In addition, applicants must also be able to meet the NHS
funding criteria set out by NHS Bursaries:
(http://www.nhsbsa.nhs.uk/Documents/Students/FAQ_3_Am_I_eligible_for_an_NHS_bursary_V5_02.2014.pdf)
13. Date of arrival in the UK (if applicable) …………………………………….
14. Have you been resident outside the United Kingdom in the last 3 years YES / NO
[You must have lived in the UK for the last 3 years OR, if an EU student, in your EU country for the last 3 years]
If Yes, please give details………………………………………………………………………
……………………………………………………………………………………………………..
15. Do you have full residency and employment rights in the UK?
YES / NO
[Overseas students must have a letter from the Home Office stating that they have indefinite leave to remain
in the UK]
16. In order to assist us in trying to ensure that you are able to fully take part in this programme, please let us know if
you have any access requirements or individual needs that we should be aware of.
……………………………………………………………………………………………………..
……………………………………………………………………………………………………...
17. Educational Record
All Academic Qualifications
Give full details, with supporting evidence such as copies of certificates & transcripts, of qualifications
including final classification/GCSE and A level grade(s) [most recent (or current) first]. If you are currently
studying for a qualification please include details here.
Dates
From
To
Name and Location of
School/College/University
Qualification
Eg AS / A2
/ GCSE
Course Title/Subject
Grade
18. Professional qualifications
Give full details, with supporting evidence, of qualifications
Dates
19.
Awarding
Institution /
University
Details
Work experience (most recent first)
Dates
Place of employment
From
To
Position held / duties involved
20. Indicate areas of experience that you feel would relate to this programme.
21. Personal statement: Explain in no more than 500 words, why you wish to study Physiotherapy (include information
on your knowledge and experience of Physiotherapy in your statement). This can be attached as a separate document.
22. Confirmation of Support (if applicable)
If you are applying for secondment from your work then please supply a letter of support from your manager to
undertake the programme.
References
Would you please supply the names, titles and full addresses (including postal codes) of two referees. In order to
save time, applicants are asked to pass on the two enclosed letters to the referees of their choice.
One of these must be an academic reference. They must be on headed paper (where applicable) and signed.
a. Work
Name
Job Title
Address
Post Code
Telephone
Email
b. Academic
Name
Job Title
Address
Post Code
Telephone
Email
23. Have you applied to study at this University before? If so, please give details
24. Have you undertaken study, at any time, on an Physiotherapy qualifying programme in the UK?
If the answer is ‘Yes’ please give details of:
(i)
(ii)
(iii)
(iv)
Establishment…………………………………………
Year of commencement……………………………..
Year of leaving………………………………………..
Reason for leaving……………………………………
25. How did you find out about the course?
26. Do you have your own transport?
YES / NO
27. Disclosure of criminal convictions, important notice for students re:
The Rehabilitation of Offenders Act 1974
In order to protect the public, the training for which application is being made (because of the nature of the work
concerned) is exempt from Section 4 (2) of the Rehabilitation of Offenders Act 1974, by virtue of the Rehabilitations
Act 1974 (Exceptions) Order 1975. You are required therefore to reveal, in relation to this application, any information
you may have concerning prosecutions, cautions or convictions including those which would otherwise be
considered as ‘spent’ and which may be considered as relevant to suitability for employment. Any such information
given will be completely confidential and will be considered only in relation to your application for this programme. In
order to fulfil this requirement, would you please complete the following details. Please note that if you are offered a
place on this programme any information you provide will be verified via the Disclosure & Barring Service (formally the
Criminal Records Bureau) (enhanced disclosure) which shows all cautions as well as convictions. Failure to provide
a full declaration may result in termination of your place on the course.
Disclosure of a conviction or caution does not necessarily mean that you will not be offered a place. An applicant’s
suitability will be looked at as a whole, in the light of all the information available. A main consideration will be
whether the offence is one which would make an applicant unsuitable to work in the health care sector, particularly
with children or young people.
28. CRIMINAL CONVICTIONS DECLARATION
Have you been convicted of a criminal offence, been bound over or cautioned, or are you currently the subject of
any police investigations, which might lead to a conviction, an order binding you over or a caution in the United
Kingdom or any other Country?
YES / NO (please delete as appropriate)
IF YES PLEASE ENTER BELOW DETAILS OF ANY CONVICTIONS OR CAUTIONS
Please include in which Authority/Country the offence, binding over/caution occurred
Offence
Date of Conviction
Sentence
29. FITNESS TO PRACTISE
Have you been, or are you currently, subject to any investigations and fitness to practise proceedings by an
appropriate licensing or regulatory body, and/or have you been subject to any disciplinary proceedings in the
workplace, in the UK or any other country?
YES / NO (please delete as appropriate)
IF YES please give:
1) Details of the proceedings………………………………………………………………
2) Date of proceedings………………………………………………………………………
3) County & name and address of licensing or regulatory body………………………..
I certify that the above information and any supporting information attached is correct and accept that false
information given may result in the withdrawal of any subsequent offer of a place on the programme. I further
understand that all offers are subject to a satisfactory medical assessment and satisfactory enhanced
Disclosure & Barring Service (formally the Criminal Records Bureau) disclosure.
Signature of applicant .......................................................................................
Date .................................................................
Please return the completed form to:
Ian Humberstone
School of Health and Human Sciences
University of Essex
Wivenhoe Park
COLCHESTER
Essex CO4 3SQ
E ipl@essex.ac.uk
Data Protection Act 1998
The University of Essex has a notification under the Data Protection Act 1998 to enable it to hold and process personal
data about its students for the purposes of maintaining their academic and related records. The information supplied on
this form will be held under the terms of the Act; it will be kept secure and accurate and will only be disclosed to people
who have a need to know in accordance with the Act.
This form will be detached.
Please complete the attached form and return it with your application.
The information you provide will be held on database and will only be used for statistical analysis by HESA and certain
other bodies that deal with the funding of education.
Thank you.
Personal Details
Last name
Title (e.g. Mr, Mrs, Ms)
First name(s) (for
official purposes)
Preferred first name
Date of birth
Equal Opportunities
Gender *delete as necessary
MALE / FEMALE *
Your Nationality
Your Ethnicity (please tick):
White
White British
White Irish
Other White Background
Black or Black British
Black or Black British - Caribbean
Black or Black British - African
Other Black background
Chinese
Chinese
Other Ethnic (please describe)
Other Ethnic background
34
Asian or Asian British
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Other Asian background
Mixed
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Other Mixed background
80
I do not wish to disclose my ethnicity
11
12
19
21
22
29
31
32
33
39
41
42
43
49
98
Description: ……………………………….
Disability (please tick any which you consider apply to you).
In addition to providing information for HESA, completion of this section will assist the University in understanding the
needs and requirements of disabled staff and also allow us to work towards meeting our obligations under the Disability
Equality Duty.
00
No known disability
51
Specific learning disability (such as dyslexia or dyspraxia)
52
General learning disability (such as Down's syndrome)
53
Cognitive impairment (such as autistic spectrum disorder or resulting from head injury)
Long-standing illness or health condition (such as cancer, HIV, diabetes, chronic heart disease, or
54
epilepsy)
55
Mental health condition (such as depression or schizophrenia)
Physical impairment or mobility issues (such as difficulty using arms or using a wheelchair or
56
crutches)
57
Deaf or serious hearing impairment
58
Blind or serious visual impairment
96
Other type of disability
97
I do not wish to provide this information