Application Form for a Course at East Durham College
Date received:
Please complete clearly in CAPITALS
Please complete BOTH sides of the application form.
PART A – YOUR PERSONAL DETAILS
A1 First Name
A2 Surname/Family Name
A3 Date of Birth
A4 House/Flat Number
A5 Street/Road
A6 Town/City
A7 Postcode
A8 Email address
A9 Mobile Number
A10 School/College attending or last attended (if under 19yrs)
PART B – QUALIFICATIONS (please list any qualifications already achieved or are expected to achieve)
Level e.g
GCSE/NVQ
SUBJECT
Grade or
predicted grade
PART C – YOUR COURSE CHOICE
B1 Which course(s) are you applying for?
PART D – TEAM EAST DURHAM
Students MUST enrol on a full-time academic course to run alongside Team East Durham.
Basketball
Football
Boxing
Rugby
Dance
Date taken (to
be taken)
PART E – DISABILITIES
Please mention any disability, medical condition or special learning needs that you may have which could affect your studies
(Support is available in College to help and assist Learners with difficulties or disabilities).
01 Visual Impairment
09 Profound/complex disabilities
02 Hearing Impairment
10 Aspergers Syndrome
03 Disability affecting mobility
90 Multiple disabilities
04 Other physical disability
97 Other
05 Other medical condition
98 No disability
06 Emotional/Behavioural difficulties
99 Not known/not provided
07 Mental health difficulty
08 Temporary disability after illness
PART F – LEARNING DIFFICULTIES
01 Moderate learning difficulty
20 Autism spectrum disorder
02 Severe learning difficulty
90 Multiple learning difficulties
10 Dyslexia
97 Other
11 Dyscalculia
98 No learning difficulty
19 Other specific learning difficulty
99 Not known/provided
PART G – ETHNICITY
31 White – British
41 Asian/Asian British – Bangladeshi
32 White – Irish
42 Asian/Asian British – Chinese
33 White – Gypsy or Irish Traveller
43 Asian/Asian British – Any other Asian background
34 White – any other White background
44 Black/Black British – African
35 Mixed/Multiple ethnic group – White and Black Caribbean
45 Black/Black British – Caribbean
36 Mixed/Multiple ethnic group – White and Black African
46 Black/Black British – Any other Black background
37 Mixed/Multiple ethnic group – White and Asian
47 Arab
38 Mixed/Multiple ethnic group – Other
98 Other
39 Asian/Asian British – Indian
99 Not Known/Provided
40 Asian/Asian British - Pakistani
PART H – WHERE DID YOU FIRST HEAR ABOUT THE COURSE/COLLEGE
Careers/School Event
Family Member/Friend
College Leaflet
School
College Prospectus
Job Centre
College Website
Word of mouth
PART I - DECLARATION
I understand that by signing this form I am consenting to the processing of my data by East Durham College including data of a
sensitive nature contained in this form or any other data the College may obtain from me or other people. I understand that I am
agreeing to the processing of such data for any purposes connected to my studies, health and safety whilst on college premises, or
for any legitimate reason, in accordance with the requirements of the Data Protection Act 1998.
Signature:
Date:
Return your completed application form to:
Student Services, East Durham College, Willerby Grove, Peterlee, County Durham, SR8 2RN