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Short Courses Office, Plumpton College, Ditchling Road, Plumpton, East Sussex, BN7 3AE
Telephone: 01273 892035 Email: pd@plumpton.ac.uk
Personal Details
Surname:
Course name 1:
Forename(s):
Date of Birth:
Start date:
Course Code:
Nationality:
Tuition Fee:
Gender:
Course name 2:
No:
Course Code:
Tuition Fee:
Contact Details
Address:
Promotional Code:
Prior Attainment
Postcode:
Home Tel:
Mobile Tel:
Email:
Criminal Record
Yes
No
01 Visual impairment
02 Hearing impairment
03 Disability affecting mobility
Residency
British
Pakistani
Bangladeshi
Irish
Chinese
African
Caribbean
Indian
No
Ethnic Origin
Yes
Arab
Any Other Ethnic group
01 Moderate
learning difficulty
02 Severe learning difficulty
10 Dyslexia
11 Dyscalculia
98 No learning difficulty
Signed:
Date:
Employee/Student/
Former Student
Radio
Exhibition/Show
Newspaper/Magazine
Leaflet
Careers Office
Address:
Internet
Careers Fair
Other:
Friend or Relative
Postcode:
Employment Status
Telephone:
Authorising office name:
I am in paid employment
I am self employed
Yes
No
Authorised signature:
Date:
Enrolments cannot be processed without a signature.
Name of company:
Address:
Three
BANK TRANSFER
Two
Amount to Charge
Signature
I declare that to the best of my knowledge the information
given above is correct and that if accepted, I agree to comply
with the College rules and regulations. I have read and
understand the college policy on refunds / course cancellation.
I confirm that I have been given sufficient guidance on course
suitability, entry requirements, progression, financial advice and
learning support. I agree to attend regularly and pay any
relevant examination / registration fees. I agree to submit any
required work and enter / sit any required examinations as part
of the course.
Signed (student):
m m
Expiry date:
m m
Issue no (Switch):
Card no:
Security code:
Date:
To be countersigned by parent / guardian if under 18.
Signed (parent / guardian):
Date:
Print name:
Relationship:
How We Use Your Personal Information - The personal information you provide is passed to the Chief Executive of Skills Funding (the Agency)
and, when needed, the Department for Education, including the Education Funding Agency to meet legal responsibilities under the Apprenticeships, Skills, Children
and Learning Act 2009, and for the Agencys Learning Records Service (LRS) to create and maintain a unique leaner number (ULN). The information you provide
may be shared with other organisations for education, training and employment related purposes, including research. Further Information about use of and access to
your personal data and details of organisations with whom we regularly share data are available at: http://skillsfundingagency.bis.gov.uk/privacy.htm. This activity has
been directly or indirectly part-financed by the European Social Fund - helping develop employment by promoting employability, business spirit and equal
oppurtunities and investing in human resources.