14 -16 Courses for Schools and Home Educated
APPLICATION FORM 2016 - 2017
Schools should return this application form and school reference form by Friday 11th March 2016
to: Val Orchin, Plumpton College, Ditchling Road, Plumpton, East Sussex BN7 3AE.
Interviews commence Monday 18th April 2016 at the course venue.
Note: Incomplete forms will be returned and may delay your application. Completed application form does not confirm place on course.
Name of School attending:
APPLICANT DETAILS
Surname:
Male / Female (circle)
Forenames:
Address:
Post Code
Tel. No. (home)
Applicant’s mobile
Applicant’s email
Name(s) of person(s) you live with for correspondence
EMERGENCY CONTACTS Names of parents / guardians / next of kin
Mr/Mrs/Miss/Ms/Other
First Name
Surname
Relationship to applicant
Contact tel nos. (work/mobile)
Email
Mr/Mrs/Miss/Ms/Other
First Name
Surname
Relationship to applicant
Contact tel nos. (work/mobile)
Email
SV1/Application form
1
NATIONALITY:
ETHNIC ORIGIN (Please (√)
White
Date of Birth:
Asian/Asian British
English/Welsh/Scottish/Northern Irish/British
Indian
Pakistani
Irish
Bangladeshi
Chinese
Gypsy or Irish Traveller
Any other Asian background
Any Other White Background
Black /African/Caribbean/Black British
Age (as at 31.8.16):
Mixed/Multiple Ethnic Group
African
White and Black Caribbean
Caribbean
Any other Black/African/Caribbean background
White and Black African
Other Ethnic Groups
White and Asian
Any other Mixed/Multiple Ethnic background
Arab
Any other ethnic group
Do you have a learning difficulty or disability? (Please (√)
YES
*
dyslexia
asthma
dyspraxia
*
emotional/behavioural difficulties*
autistic spectrum disorder
wheelchair user
aspergers syndrome
moderate learning difficulty
ADHD
severe learning difficulty
visual impairment
*
epilepsy*
other physical disability
dyscalculia
temporary disability after illness
diabetes
*
heart or lung condition
*
*
*
hearing impairment
other medical condition
eg. Allergies/skin disorder
*
multiple learning difficulties
*
mental illness
*
other specific learning difficulty
*
disability affecting mobility
NO
statement of educational needs (please attach)
other
*
*
*
*Please provide further details:
Do you receive free school meals? (Please (√)
YES
NO
YES
NO
YES
NO
MEDICAL INFORMATION
Have you had a tetanus injection? (Please (√)
(RECOMMENDED FOR ALL COURSES)
Are you awaiting any surgical operation or hospital appointment? (Please (√)
Date:
Details:
DETAILS OF YOUR DOCTOR
Name:
Tel. No:
Address:
Post Code
SV1/Application form
2
MORE INFORMATION ABOUT YOU
The College has a duty of care to all learners, particularly those under the age of 18. In view of this all learners are
required to state if they have a youth offending order/criminal conviction, including spent sentences and cautions.
All information given will be treated as sensitive data under the Data Protection Act 1998.
Do you have any Youth Offending Orders/Criminal Convictions? (Please √ )
YES
NO
If YES, please give further details:
Date of Order / Conviction
Offence
Outcome/Sentence
14 - 16 COURSES – SEPT 2016 START
Select Level and Course
with a tick (√)
Course details and availability
Write preferred day in box below
PLUMPTON MAIN SITE: Years 10/11 - Day Release 14 - 16
Day of course allocated will depend on demand
Level 1
Level 2
Please tick (√)
Please tick (√)
Agriculture
Either Monday or Tuesday
Countryside & Environment
Either Monday or Tuesday
Creative Metal Crafts
Either Monday or Tuesday
Fish Husbandry
Either Monday or Tuesday
Floristry
Either Monday or Tuesday
Forestry
Either Monday or Tuesday
Not available
Game Management
Either Monday or Tuesday
Not available
Horse Care
Either Monday or Tuesday
Horticulture
Either Monday or Tuesday
Machinery Maintenance
Either Monday or Tuesday
Motor Vehicle Maintenance
Either Monday or Tuesday
Small Animal Care
Either Monday or Tuesday
Not available
Not available
Not available
Not available
Not available
Not available
IVYLAND FARM, NETHERFIELD: Years 10/11 - Day Release 14 - 16
Level 1
Level 2
Please tick (√)
Please tick (√)
Agriculture
Day to be confirmed
Horticulture
Day to be confirmed
Small Animal Care
Monday or Tuesday
Explorer Yr 10 (1 day)
Monday
Not available
Explorer Yr 10 (2 days)
Monday and Wednesday
Not available
Tracker Yr 11 (1 day)
Tuesday
Not available
Tracker Yr 11 (2 days)
Tuesday and Friday
Not available
FLIMWELL: Years 10/11 - Day Release 14 - 16
Woodland Studies
Wednesday
Countryside & Environment
Wednesday
Level 1
Level 2
Please tick (√)
Please tick (√)
Not available
Not available
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SV1/Application form
THE FOLLOWING SECTIONS A - C MUST BE COMPLETED
A) Why have you chosen this College course and what are your expectations of the course?
Detail any career aims.
B) How do you think College will differ from school?
C) What are your interests/hobbies?
PARENT/GUARDIAN, LEARNER AND SCHOOL DECLARATION
If
(name of applicant) is offered a place on the course:
•
I acknowledge that the Home School ultimately has responsibility for the learner whilst at Plumpton College. Plumpton
College reserves the right to exclude from the course any learner who fails to meet an accepted standard of behaviour.
All discussions, agreements and communications relating to discipline will be made via the Home School.
•
I consent to my son/daughter taking part in all activities which form part of the course, including offsite visits with
College staff.
•
I consent to my son/daughter travelling independently to and from College/Outcentre.
•
I give permission for photographs/video clips to be taken of my son/daughter for the purposes of
marketing/advertising/administration.
•
I understand that my son/daughter will be unsupervised during lunch and break times.
•
I agree to Plumpton College processing personal data or other data about my son/daughter which the College may
obtain from me or other people whilst he/she is a student. I agree to the processing of such data for any purposes
connected with his/her studies or his/her health and safety whilst on the premises or for any other legitimate reason
directly concerned with his/her education.
•
I acknowledge that whilst my son/daughter is on the course I have responsibility to ensure regular attendance and
compliance with the College’s Code of Conduct.
Parent/Guardian Signature
Date
Learner Signature
Date
School Coordinator Signature
Date
SV1/Application form
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