The name of the course you are applying for

Site (please consult the course page on this website or the relevant course guide to find out at which site your course is available):
Beverley
Bridlington
Hull

Other (please specify):

Your details

Title (please tick one):
Mr
Mrs
Miss
Ms
Other

If you chose "other" please give details:

First name(s):

Surname:

Address (including postcode):

Age:

Date of birth:

Telephone (home):

Telephone (mobile):

Email address:

Have you lived in the UK or EU for the past three years without any restrictions on your residency?
Yes
No

Name and address of next of kin:

Next of kin's telephone number:

Next of kin's relationship to you:

Education

Please list the schools and colleges you have attended since the age of 11. Include the date you started and the date you finished at each.

Examinations taken or to be taken

Please list the exams you have taken or are about to take. For each, please include the examining board, subject, level and the grade achieved or predicted:

Before the offer of a place can be made, we will need two references. Please give the name and address of your headteacher, employer or other people from whom references may be obtained:

Jobs held, full or part-time

For each job, please give details of the employer, a brief job description, the date you started and the date you finished:

Why would you like to join this course?

Have you any experience of the subject you are applying to study?
Yes
No

If YES, please give brief details:

Please give details of any leisure interests, hobbies or clubs etc:

Have you any disability or health problems?
Yes
No

Are you registered disabled?
Yes
No

Do you have any other support requirements?
Yes
No

If you have answered YES to any of the three questions above, please give brief details:

DATA PROTECTION STATEMENT

Please read this Data Protection Statement carefully. By signing this Application Form you are indicating your consent to the collection and use of your personal data as set out below.We collect and process the personal data you provide on this Application Form to help us to decide whether to offer you a place on a course at East Riding college. If we offer you a place, it will be subject to us obtaining satisfactory references from your previous school, employer and/or other referee named on this Application Form.All of the data we collect about you is handled and stored securely in wither hard or electronic form within the College’s various departments. We ask for contact details or your next of kin so that we can contact him or her in an emergency. We may disclose details of medical conditions you have told us about to your potential tutor or to third parties where it is necessary for us to help safeguard your health and safety or the health and safety of others. We may also use this information to help us to tailor our facilities to your requirements. Details of your ethnic background are collected solely for the purpose of monitoring the promotion of equal opportunities within the College.We may use your personal data to send you information relating to the various courses and services we offer where we believe these may be of interest to you. We will neither sell your personal data to third parties nor disclose it to them for the purpose of direct marketing without your consent. If you do not wish us to send you information relating to the College’s own courses and services, please tick here [ ] or write to the Data Protection Officer at Longcroft Hall, Gallows Lane, Beverley, East Yorkshire, HU17 7DT with details of your request.We have notified the Office of the Information Commissioner of our data processing activities: our Data Protection Notification number is Z6977440. A list of third parties to whom we have disclosed personal data about you is available on request. We will give you a copy of the data which we hold about you upon payment of a fee.

How did you hear about the course (please tick one or more)?
Carrers advisor/Connexions
School
College
JobCentreSchool
Radio
Newspaper
Friend or family
Marketing event
Former student
College open event
College website

Other (please specify):

What is your ethnic group? Please tick ONE from the following options:

Asian or Asian British
Bangladeshi (11)
Indian (12)
Pakistani (13)
Any other Asian background(14)

Black, black British, black English, black Scottish or black Welsh
African (15)
Caribbean (16)
Other (17)

Chinese or Chinese British
Chinese (18)

Mixed
White and Asian (19)
White and black African (20)
White and black Caribeean (21)
Any other mixed background (22)

White
English (23)
Scottish (26)
Welsh (27)
Irish (24)
Any other white background (25)

Other:
Any other (98)

By submitting this form, you declare that all the information you have given is correct to the best of your knowledge.