Pathway Staff Enrolment Form 2014

1. ©Pathway Staff Training Enrolment form. Version 1 – Feb 14 1
Pathway Staff Training Enrolment Form Learner Reference: ______________________
Section 1 – Learner Information
Section 2 – Support
Home Address:
Date of Birth: Age
Home Postcode:
National Insurance Number:
Forename(s):
Home Telephone:
Title: Gender: Surname:
Mobile Telephone:
Email Address:
Whom should we contact in case of
emergency?
Name:
Telephone:
Mobile:
Relationship:
Please indicate the ethnic group to which you belong:
White British 31
White Irish 32
White Gypsy or Irish Traveller 33
White (Any Other White Background) 34
Mixed White & Black Caribbean 35
Mixed White & Black African 36
Mixed White & Asian 37
Mixed (Any Other Mixed Background) 38
Other 98
Not Known/Not Provided 99
Asian/Asian British Indian 39
Asian/Asian British Pakistani 40
Asian/Asian British Bangladeshi 41
Asian/Asian British Chinese 42
Asian/Asian British (Any Other Asian Background) 43
Black/Black British African 44
Black/Black British Caribbean 45
Black/Black British (Any Other Black Background) 46
Arab 47
Do you consider that you have a disability? If yes, please specify:
Visual Impairment 01
Hearing Impairment 02
Disability Affecting Mobility 03
Other Physical Disability 04
Other Medical Conditions (e.g. Epilepsy) 05
Emotional/Behavioural Difficulties 06
Mental Ill Health 07
Temporary Disability after Illness 08
Profound/Complex Disabilities 09
Multiple Disabilities/Other 90
Do you consider that you have a learning difficulty? If yes, please specify:
Moderate Learning Difficulty 01
Severe Learning Difficulty 02
Dyslexia 10
Dyscalculia 11
Other Specific Learning Difficulty 19
Autism Spectrum Disorder 20
Multiple Learning Difficulties 90
Other 97
Do you feel that you may need support for your course? If yes, please specify:
English is not my first language 05
Help with Coursework 06
Other Needs 07

2. ©Pathway Staff Training Enrolment form. Version 1 – Feb 14 2
Section 3 – Job role
Job Role: ____________________________________________________
Section 4 – Course/Training/Programme Details
Course Code Course Title Start Date Planned End Date
Delivery
Method
This section will be completed by a member of
the Training staff.
Learner
Reference:
Surname: DOB:
Please use this space to provide a rational as to why you need this training & how it will help you in your job role:

3. ©Pathway Staff Training Enrolment form. Version 1 – Feb 14 3
Section 5 – Payment and Learner Declaration
Payment:
Course/Programme/Training cost £_____________
Yes No
Employee paying themselves for the course/training in full
Employer paying for course/training in full
Employer contributing towards cost (how much £ )
I declare that the information given is complete and correct. I agree to be responsible for payment of all fees (including
tuition, examination, registration and equipment) in connection with the course(s) for which I have enrolled and to inform
the College of any change of circumstances including my entitlement to welfare benefit. I agree to be bound by conditions of
entry and College regulations, including participating in Functional Skills relevant to my course. Should I withdraw early from
my Learning Aim I understand that I may be responsible for payment of ALL fees.
I confirm that I have received appropriate guidance in making my choice of learning programme and I understand:
• Entry requirements & any possibility of accreditation of prior learning.
• Whether the Learning Aim suits my abilities, interests & needs.
• Assessment requirement, qualifications & learning outcomes.
• Any implications for my career or progression to further study.
• Classes may be closed if not enough learners attend.
• Educational & practical support which is available.
• Course requirements such as study time, equipment, costs.
• Alternative Learning Aim options in this College or elsewhere.
Employee Signature:
Date:Employee Name: