EYPS Application Form by 40Cx11

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									                                                     EYPS APPLICATION FORM

                                                                PERSONAL DETAILS

         Title:                                                                                Date of Birth:

                                                                                        National Insurance
Forename(s):
                                                                                                   Number:
                                                                                        Previous Surname
    Surname:
                                                                                             (if applicable):

   Address &
   Postcode:


 Tel (Home):                                                                                    Tel (Mobile):

       E-mail
     Address:

                                                                   QUALIFICATIONS

Highest Academic                                                                                                                          Year
Qualification Level 6:                                                                                                                awarded:
Highest Relevant
                                                                                                                                          Year
Qualification (in early
                                                                                                                                      awarded:
years/childcare):
Awarding Institution
(e.g. UWE, Bath Spa):
                                           GCSE Mathematics at grade C or above (or equivalent):                                              Yes               No
                                          (Electronic version: double-click relevant box and change default value)
                                                   GCSE English at grade C or above (or equivalent):                                          Yes               No


                                                  (EARLY YEARS) EMPLOYER DETAILS
  Job Title:

     Age group currently working with:                                                                                                Full Time              Part Time

   Setting
 Name and
  Address:

   Setting Contact Name:

                  Setting Tel:

  Setting E-mail Address:
                     Local Authority Nursery Class in mainstream school                                              Private Setting
                     Local Authority Children’s Centre                                                               Voluntary Setting
     Setting         Local Authority (Advisor/Advisory Teacher)                                                      Independent Setting
      Type:          FE College (Lecturer in Early Years)                                                            Child Minder

                     Other (please state)..................................................................................................................................
               Is Setting in receipt of Graduate Leader Funding from the Local Authority?                                                   Yes               No

                                                                          Is Setting registered with Ofsted?                                Yes               No


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                                                                                   PATHWAY
                                     Please indicate which particular pathway you are interested in, if known.

     Full Time (12 month)                                                                          Validation Only (4 month)

     Long EPD (15 month)                                                                           Short EPD (6 month)


                 PLEASE OUTLINE BELOW WHY YOU WISH TO UNDERTAKE THE EYPS COURSE.
                                                                     (Please use no more than 150 words)




                                                                               REFERENCES
                                          Please give the names and addresses of two referees.
                          At least one referee should be able to comment on your academic/professional ability.

Referee (1)                                                                                    Referee (2)




                                                                         CURRICULUM VITAE
                          Please attach a copy of your CV and/or employment history when returning this form.
                                    I confirm my CV/employment history is attached / enclosed.                                                         Yes              No


                                                                          LOCAL AUTHORITY
      Local Authority of my Employer is:
                          My Local Authority is:
              (If applying for Full Time course)
                          Would you be happy to be contacted for feedback about EYPS?                                                                Yes              No


                                                                                EYPS at UWE
                                             Where did you hear about the EYPS course offered by UWE?

     UWE website                                                     EYPS student/graduate                                          Search Engine (e.g. Google)*
     CWDC                                                            UWE events/open days                                           Other*
     Flyer/Poster                                                    Newspaper/Magazine*

*Details: ..............................................................................................................................................................................



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                                                             ALTERNATIVE EYPS PROVIDER

                                            Have you also applied to another EYPS provider?                                                    Yes              No


Details of Provider(s): .........................................................................................................................................................


                                                                   CRIMINAL CONVICTIONS

    Do you have any criminal convictions that will prevent you from working with children?                                                             Yes             No


                                             EQUAL OPPORTUNITIES INFORMATION (optional)
                       Gender:                   Male                 Female                             Ethnicity:

    Registered Disabled:                           No                   Yes**                  Country of Birth:

    **Details of disability:


                                                                            DECLARATION

If the University of the West of England has reason to believe that I or any other person have given false information or have omitted
any information requested in the instruction or application form or made any misrepresentation, the University will take whatever
steps considered necessary to establish the authenticity of my application. I accept that if I do not fully comply with these
requirements, the University reserves the right to cancel my application and I shall have no claim against the University. I
understand that if my application is unsuccessful, the information provided will be retained by the University of the West of England
for a period of one year.

I agree to the University of the West of England (UWE) sharing my name, telephone number, E-mail address and work setting name,
address and E-mail address (if relevant) with local authorities for the purpose of providing future support to EYPs.

I confirm that the information given on this form is true, complete and accurate.




Signed: ..................................................................................................................... Date: ...............................................
        If returning by email, please note emailing of this form constitutes your personal confirmation of the above in lieu of a signature.


                                                              The Data Protection Act 1998
The information which you give on your application form will be used for the following purposes only:
         To enable the university to compile statistics, or to assist other organisations or individual research workers to do so, provided that no
          statistical information which would identify you as a person will be published.
         To enable your application for entry to be considered.                              To enable the university to initiate your student record.
         To inform the relevant Local Authorities of your registration on an EYPS Pathway.




                                                                          ADMIN ONLY                                                                              V:12/08

Application Received:                                                                    Mentor allocated:
ISIS No:                                                                                 Candidate Reg. No:




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