*Surname:

*Forename(s):

*Date of Birth: - -

*Male/Female: Male Female

*Address (line 1):

*Address (line 2):

*Address (line 3):

Address (line 4):

Address (line 5):

Address (line 6): *Postcode:

*Landline Tel. No:

Mobile No.:

Email Address:

*Have you been a resident of this country for at least 3 years: Yes No

If No, state the date of entry to the UK/EU:

Country of Origin (according to passport):

*Parent or Guardian Names

Mr:

Mrs:

*Do they live at the same address as you: Yes No

Their Address (if different from yours):

Address (line 1):

Address (line 2):

Address (line 3):

Address (line 4):

Postcode:

*Which School/College do you currently attend:

Town:

*Recent School Leavers, Please Name School Attended:

Town:

Date Left School: - - (DD/MM/YYYY)

*Please give details of the course(s), which you would like to study at College.

Russell Group The College's Russell Group is for students expecting A*/A GCSE grades (see page 11 of the prospectus for details). If you expect high GCSE grades and wish to be considered for a place on this program , please select:

*Would like to apply for a place on the Russell Group programme:

Yes: No: Dont Know:

*Please indicate your preferred campus. Your choice of campus can be changed.

Town Centre
Farnworth

Have you applied, or are applying to another College, Sixth Form or 11-18 school?

Yes
No

If yes, please state which College/School(s).

*Please list below any examinations (GCSEs A Level and Others) you will have taken before starting your college course:

Sports Academies:

Are you already competing in sports for a team at a high level? (see page 11 of the Prospectus for the further details).

Please select if you wish to be considered for a Sports Academy place at college in any of the follwing :

Boys' Football

Girls' Football

Cricket

*The College is committed to equal opportunities. We would like you to give us the following information to help us monitor our policy.

Asian or Asian British - Bangladeshi Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Any other Asian background Black or Black British - African Black or Black British - Caribbean Black or Black British - Any other black background Chinese Mixed - White and Asian Mixed - White and Black African Mixed - White and Black Caribbean Mixed - Any other mixed background White - British White - Irish White - Any other white background Any other Not known Romany / Gypsy Please Select

*To comply with equal opportunities legislation, the College wishes to monitor the religious affiliations of the student body. Please select one from the list.

Christianity Hinduism Islam Judaism Other No religious affiliation Do not wish to state Please Select

*Select the first and second language spoken at home primarily.

Please state the career(s) you would like to pursue. If unknown, leave blank.

Do you wish to progress to University or a College of Higher Education?

Yes
No
Maybe

Please provide any additional information about yourself relevant to this application.
(Special interests, hobbies, work experience, positions of responsibility)

*Health: Is your health good?

Yes
No

Please give details of any medical condition or disability and any way in which we may help you at your interview and whilst at college.

*The Disability Descriminations Act identifies support needs as listed below. If you feel that any of the following categories apply to you, please choose where appropriate and add comments accordingly.

Visual impairment
Hearing Impairment
Disability affecting mobility
Other physical mobility
Other medical condition(eg. epilepsy, athsma, diabetes)
Emotional/behavioural difficulties
Mental ill health
Temporary disability after illness or accident
Profound complex disabilities
Asperger's Syndrome
Multiple disabilities
Other
No disability
Not known/information not provided

Moderate learning difficulty
Severe learning difficulty
Dyslexia
Dyscalculia
Other specific learning difficulty
Autism Spectrum disorder
Multiple learning difficulty
Other
No learning difficulty

*Support: Have you received any special learning support at school? (eg. Have you had extra time in exams or a statement of educational need?)

Yes
No

If Yes, please give brief details:

Would you like a Learning Support member present at your interview?

Yes: No: