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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:
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