HIGHLANDS SCHOOL

							   THE SIXTH FORM @ WESTMINSTER ACADEMY
Please complete IN BLOCK CAPITALS and return to:
Sixth Form Team, Westminster Academy, 255 Harrow Rd, London W2 5EZ

STUDENT’S PERSONAL DETAILS

Family                                 Middle                         First
Name                                   Names                          Name
Chosen Name (if different from above):


Date of Birth               /              /                  Gender (tick)    Male       Female

                                 st
    Age (on entry to Sixth Form 1 Sept 2012)          years                months

Address
Number &                                               Home
  Road                                                 Phone
                                                       Mobile
  District
                                                       Phone
Town/City                                              Email
Postcode                                               Contact

Please give details of all persons who have parental responsibility and anyone else you wish to be
contacted in an emergency. Place them in the order you wish them to be contacted.

Priority:1
Title Mr/Mrs                                                    Relationship
                                Name
     etc.                                                         to child
   Address                                       Home Phone
 (if different                                   Work Phone
to students)
                                                Mobile Phone
 Postcode                                       Email Contact

Priority:2
Title Mr/Mrs                                                    Relationship
                                Name
     etc.                                                         to child
   Address                                       Home Phone
 (if different                                   Work Phone
to students)
                                                Mobile Phone
 Postcode                                       Email Contact

Priority 3:
Title Mr/Mrs                                                    Relationship
                                Name
     etc.                                                         to child
   Address                                       Home Phone
 (if different                                   Work Phone
to students)
                                                Mobile Phone
 Postcode                                       Email Contact
FAMILY INFORMATION

Brothers’ and sisters’ names and ages




Would either parent be interested in becoming a Governor?             YES/NO

Please mention any special skills parents or grandparents may be willing to use to help the Academy.




Please mention any business or industry contacts (for example, parents’ employers) who may be willing to
help the Academy e.g. with work experience placement:




Do you have any legal order relating to you? YES/NO
If so, please specify.




TRAVEL ARRANGEMENTS (please tick)
Bus                Tube/train                               Cycle                  Walk
Car                           Taxi                          Other

DIETARY NEEDS




MEDICAL INFORMATION

Doctor:
Address:




Telephone:

Essential medical information (e.g. disabilities, chronic conditions, allergies)




Details of any drugs you take and how you wish them to be administered:
ETHNICITY:
Ethnic origin:                           Home                                    Religion:
                                         Language:

INFORMATION TECHNOLOGY

Do you have a home computer which you may use? YES/NO
If so, please give some details of type and software available.




TALENTS AND STRENGTHS What are your interests and activities outside of the classroom? E.g.
involvement in clubs, work experience, hobbies, sports, music, positions of responsibility, etc.




COLLEAGUES

Please mention the names of any other students you may know in the Academy and who you work well with.




PASSPORT

                 Nationality   as on passport
    Date of arrival in UK      if applicable
                               Country(ies) of residence in which parents have
                  Domicile
                               been living for the last 3 years

PREVIOUS EDUCATION

  Current School

     Address
                                                                                        Local Education Authority
                                                                                          in which YOU reside
     Year of entry

                                                                                                       Page 2
EXAMINATIONS
Please give details of examinations taken or to be taken:
Type? E.g. full GCSE,       Subject                 Year to be taken or          Predicted grade   Actual Grade
GNVQ, BTEC, short                                   taken                                          if already
course etc.                                                                                        taken
COURSE SELECTION - International Baccalaureate Diploma Programme

Circle one subject from each group. In total, you must choose three Standard Level (SL) subjects and three
Higher Level (HL) subjects.

Entrance requirements:
    - Seven GCSE subjects at grade B or better, or the equivalent to this. (These subjects must include
       English Language, Mathematics and a Science.)
    - Students must have obtained a grade A/A* at GCSE in a related subject area, or the equivalent, to
       study a Higher Level (HL) subject.

IB Diploma                         Name of subject:                       Higher Level or Standard Level?
Gp 1: First Language
English A

Gp 2: Second Language              Second Language must not be the        Please note that ai is only available
French B or ai                     same as first language.                at SL.
German B or ai
Spanish B or ai
Italian B or ai
Arabic B or ai
Mandarin B or ai
Russian B or ai
Bengali B or ai

ai = beginners
B = intermediate

Gp 3:Individuals & Societies
Business and Management
Economics
History
Geography
Psychology
Information Tech in a Global
Society (ITGS)
Gp 4:Experimental Science
Environmental Systems
(SL only)
Physics
Chemistry
Biology
Gp 5: Mathematics
Mathematics HL, SL
Mathematical Studies (SL only)
Gp 6: Elective

Film (HL or SL)

Any of the subjects above*

*you may not do two languages
courses in the same language

*you may not do two maths
courses

* you may not do SL and HL in
the same subject
FURTHER INFORMATION:
Do you have a disability or a learning difficulty? Yes/No
If yes, we want to help you get the best from your course. How would you wish to let us know what you are
likely to need?
       By talking confidentially to a member of staff at interview
       By writing (please attach)
       By talking confidentially to a member of staff by telephone
       By talking confidentially to a member of staff by Email
       Through someone else such as an advocate, parent or carer, who will accompany you to your interview
If you wish to be contacted by text/phone please provide a contact number

Under the Data Protection Act 1998, this information will be held confidentially and may be used in
accordance with the Academy notification under the Act. You have a right to see any information held on you.
The details will be entered into our systems. Information will not be released to any third party.

By signing this form, you consent to*:
Your photograph to be displayed on the Academy website and other publications (name will not be used)


*Please delete if you do not consent


SIGNATURE:                                                                 DATE




When you have filled in the information on this application for, send this application form together with the next
page directly to:

Sixth Form Team
Westminster Academy
255 Harrow Road
London
W2 5EZ

sixthformteam@westminsteracademy.biz


Give the separate reference form to a teacher in your school/college.

The closing date for receipt of application forms for candidates is May 2012.
Late applicants must understand that while we want to offer you a full range of options, some classes
may be full.
                REFERENCE FOR WESTMINSTER ACADEMY
To the applicant: Please fill in your name, the course applied for and the subjects you are taking at GCSE.
DO NOT complete the predicted grades section. Hand the form to a teacher.
To the teacher: Please complete the predicted grades and the reference section below or provide us with a
copy of your standard reference that also includes the predicted grades. Please read the description of the
course the student is applying for when commenting on their suitability.
NAME OF APPLICANT :
SCHOOL:
Course applied for:   IB Diploma

GCSE Subjects to be taken               Predicted       GCSE Subjects to be taken                Predicted
                                        Grade                                                    Grade




GCSE Subjects already taken             Actual          GCSE Subjects already taken              Actual
                                        Grade                                                    Grade




The International Baccalaureate is a demanding               BTEC courses are vocational in nature.
academic course in which students opt for six
subject areas: English, second language,                     The BTEC National Diploma and Subsidiary
                                                             Diploma is a Level 3 full-time course. The BTEC
mathematics, science, humanities and an optional
                                                             National Diploma will help prepare students for
creative subject. The Theory of Knowledge is                 careers or HE, alongside up to two A Levels
studied as an integral part of subjects, and all
students have to prepare an extended 4000 word               The BTEC First Diploma is a Level 2 full-time
essay based on independent research on a subject             course.
of their choice. In addition students must take
part in some form of service to the community, a
physical challenge and creative activity.


Do you think the course is an appropriate one for the applicant?
Why?



Has the applicant had a good record of:
Punctuality?
Attendance?
Meeting deadlines?
Has the student received any learning support? Yes/No
Additional Comments



Report Writer: Signature:                                    Position
               Name                                          Date

PLEASE RETURN TO Sixth Form Team, Westminster Academy, 255 Harrow Rd, London W2 5EZ
                 Tel: 020 7121 0617      Email: sixthformteam@westminsteracademy.biz