Personal and Career Interests

We want to make sure that you get the most out of your time at college, so please tell us a little more about yourself and
your plans for the future.
Why did you choose this course at HRC?

Hertford Regional College

FULL-TIME APPLICATION FORM

What job or career would you like in the future?

Personal
Details

What are your hobbies and interests? Please tell us about any work experience, paid or unpaid.

Surname:

Person Code:

IC Initials:

Unique Learner Number (ULN):

First Name:

Male

Female

Address:

Postcode:
DATA PROTECTION STATEMENT 2010/2011
HOW WE USE YOUR PERSONAL INFORMATION
The personal information you provide is passed to the Chief Executive of Skills Funding and, where required, the Young Peoples Learning Agency for England (the YPLA) to enable
those organisations to fulfil their statutory obligations, principally under the Apprenticeships, Skills, Children and Learning Act 2009. Both organisations are registered as data controllers
with the UK Information Commissioners Office.
The Skills Funding Agency funds adult further education and skills training, including apprenticeships, in England. The YPLA is responsible for arranging the provision of funding for the
education and training of young people in England. The Skills Funding Agency processes learner data on behalf of the YPLA.
The information you provide may be shared with other organisations for purposes of administration, the provision of career and other guidance and statistical and research purposes,
relating to education or training. Other organisations include the Department for Children, Schools and Families, the Department for Business, Innovation and Skills, Local Authorities,
Connexions, Higher Education Statistics Agency, Higher Education Funding Council for England, educational institutions and organisations performing research and statistical work on
behalf of the Skills Funding Agency, the YPLA, or partners of those organisations.
The Skills Funding Agency also administers the learner registration service (LRS) which uses your learner information to create and maintain a unique learner number (ULN).

Tel No:

Mobile No:

Date of birth:

Email:

Age on August 31st 2012:

Your nationality:
Have you lived abroad other than holidays over the last 3 years?

Yes

No

If yes, please state date of entry to UK:

Further information about use of and access to your information is available at:
Skills Funding Agency: http://skillsfundingagency.bis.gov.uk/foi.htm YPLA: www.ypla.gov.uk/foi.htm
At no time will your personal information be passed to organisations for marketing or sales purposes. The YPLA, the Chief Executive of Skills Funding and their partners may wish to
contact you from time to time in respect of surveys and research to monitor performance, improve quality and plan future provision and to inform you about courses, or learning
opportunities relevant to you.

Country of normal residence (if not UK):

Country of birth:
Name and address of parent/carer

(if applicant is under 18 years or if parent's/carer's address is different from above):

Statement by the Student

I declare that the information given is correct and understand that it will be used only for the purpose set out in the consent to process, and my consent is
conditional upon Hertford Regional College complying with their obligations and duties under the Data Protection Act 1998.
I have received sufficient information and advice to make an informed decision about my choice of course.
I agree to notify the College of any change in my personal circumstances which may affect any concessions given at the time of enrolment.
I understand that all course fees/instalments remain fully payable even if I do not complete the course.
I agree to Hertford Regional College processing personal data contained within this form, or other data or images, which Hertford Regional College may obtain from me or other people,
whilst I am a student. I agree to the processing of such data for any purposes connected with my studies or my health and safety whilst on the premises or for any other legitimate reason.
I confirm that I have read the Data Protection Statement contained in the guidance notes.

Signed by Student/Parent/Guardian (delete as appropriate)

Signature for HRC

Name:
Tel No:

Mobile No:

Email:

Address:

HRC name:

Postcode:
Date:

Date:

Are you in or have you been looked after by Local Authority Care?

Yes

No

Are you a Carer in 2012?

Yes

No

Course Applied For:

Course Code

Course Title

Campus

1st Choice:

PLEASE RETURN THIS FORM TO THE CAMPUS YOU WISH TO STUDY AT

2nd Choice:

Hertford Regional College

Hertford Regional College

Please write here any dates when you are not available for interview:

FREEPOST NW4954
Broxbourne Campus
High Road, Turnford
Broxbourne, EN10 6BR

FREEPOST NW4954
Ware/Birchwood High School
Ware Campus,
Scotts Road, Ware, SG12 9BR

Copy in an alternative format is available. Please call 01992 411411.

For Office Use Only

Learning Support notified

Report requested

Received

Interview Date . . . . . . . . . . . . . . . . . . . . CNX/DNA

Initial Assessment done

Interview Date . . . . . . . . . . . . . . . . . . . . CNX/DNA

Tutor Referral Form sent

Reminder

Reference Details

Ethnic Monitoring (please describe your ethnic origin by ticking one box only)

We gather this information to help us support you on your course. Please provide details of the person you wish us to contact.

31 English/Welsh/Scottish/
Northern Irish/British
32 Irish
33 Gypsy or Irish Traveller
34 Any other white background
35 White and Black Caribbean
36 White and Black African
37 White and Asian

Referee name:

Position:

Address:

Postcode:

38 Any other mixed/

multiple ethnic background
39 Indian
40 Pakistani
41 Bangladesh
42 Chinese
43 Any other Asian background
44 African

45 Caribbean
46 Any other Black/African/
Caribbean background
47 Arab
98 Any other ethnic group
99 Not known/not provided

Tel No:

Student Status Monitoring (please tick any box that applies)

Previous School/College and Qualifications

Name and address of school/college last attended

From

To

Traveller
Asylum Seeker
Refugee

Living in a hostel or residential centre

In care

Learning Support and English for Speakers of Other Languages (ESOL)

Many students need extra support to help them with their course. If you tick any of the boxes below your application will not
be affected - it is to help us to support you.
Do you have any special needs that you wish us to know about?

Qualifications
Exam Subjects

Yes

No

Partially sighted or blind

01

Moderate learning difficulty

01

Hard of hearing or deaf

02

Severe learning difficulty

02

Physical disability (wheelchair)

03

Dyslexia

10

GCSE, A/AS LEVEL

Expected Result

Actual Result

Physical disability (non-wheelchair)

04

Multiple learning difficulties

90

NVQ, GNVQ ETC

(if known)

(if known)

Other (please give details)

You can contact the Learning Support Department to discuss your support needs in private: Learning Support Department,
Hertford Regional College, Ware Campus, Scotts Road, Ware, Herts, SG12 9JF, or call 01992 411846, or email:
learningsupport@hrc.ac.uk
What is your first language? ..
Would you like help with your English for your studies?
Yes
No

How did you find out about Hertford Regional College?

Prospectus

Newspaper Article

Connexions

HRC Website

Newspaper Advert

Employer

Search Engine

Magazine Advert

NextStep Centres

Facebook

Poster e.g. train platforms,

cinema, shopping centres

High Trees Children's Centre

College Open Day

School
School Talk from HRC
Public Library

Community Event

I am an existing student
Skills Account Course Search

Word of mouth
Careers Service

Other (please specify)................................

Where did you pick up your copy of the prospectus?

HRC Website

Open Evening

Public Library

Careers Service

Community Event

School

Information Centre

NextStep Centres

Not Known