SCHOOL LINKS SCHOOL OUTREACH INTERVIEW FORM

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SCHOOL LINKS SCHOOL OUTREACH INTERVIEW FORM Powered By Docstoc
					      Environmental and Land-based Studies
                    Diploma
                                         with




      Plumpton College as part of the East and Mid
   Sussex Environmental and Land-based Consortium
                  APPLICATION FORM 2009 – 2010
                   (To be returned to your school)
    Please complete in black ink

Section 1: School details

School attending__________________________________________________________

Diploma liaison /contact person at school (Print name)_____________________________
Contact phone details_______________________email_______________________________

Diploma liaison/ contact person at school signature____________________________________


Section 2: Learner details


 Surname: ________________________      Male / Female (circle)
                                                                 Ethnic Origin: (please )
 Forenames: ________________________________________
                                                                   White British       Pakistani
 ULN – Unique Learner Number if known                              White Other         Bangladeshi
                                                                   Black Caribbean     Chinese
                                                                   Black African       Other Asian
 __________________________________________________                Black Other         Other
                                                                   Refuse to say
 Address: __________________________________________
 __________________________________________________              Date of Birth: ________________
 __________________________________________________
 __________________________________________________              Age (as at 31.8.09): ____________

 Post Code: ________________________________________             Year Group starting
                                                                 Sept 2009:___________________

 Tel. No. (home) _________________ (mobile) ______________       Dates of school
                                                                 work experience week______________1
 e-mail ____________________________________________
                                                                                                                                         Environmental and Land-based Studies Diploma
Which Level Diploma have you chosen? Level 1, 2 or 3                                                                                                    September 2009

                                                                                                                                  Schools to forward application forms to Plumpton College by
                                                                                                                                         Friday 20th March 2009 and please send to
                                                                                                                                 Val Orchin, Schools Courses and Diploma Administrator,
                                                                                                                         Plumpton College, Ditchling Road, Plumpton, Nr Lewes, East Sussex, BN7 3AE.
Which Additional or Specialist learning have you chosen? GCSE or BTEC
                                                                                                                                                   Telephone: 01273 892 050

                                                                                                                                                  Interviews will be held weeks commencing
                                                                                                                                              Monday 20th April 2009 and Monday 27th April 2009

Prior learning/achievement? Functional Skills, GCSE’s and BTEC’s or a National award. Please give          Please note a completed application form does not confirm entry on to the programme.
grades and or levels
                                                                                                           Information provided on this form will only be used for the purposes of delivery and monitoring of the
                                                                                                           programme by Plumpton College and other statutory bodies.


EMERGENCY CONTACTS: Names of Parent(s)/Carer(s)/Next of Kin              Please indicate  who you
live with

(First name and surname)                       Relationship                Contact Tel. No.(work/mobile)   For Office Use

________________________________           ___________________             _______________________
                                                                                                           Shared Delivery PL Yes/ No.......................................HUB.........................................................
________________________________           ___________________             _______________________         Diploma Level...................Days of week delivery..........Plumpton Year 1..............HUB Year 1................

                                                                                                           Days of delivery........................Plumpton Year 2.........................HUB year 2
________________________________           ___________________             _______________________
                                                                                                           Length of programme................

Do you have an                                     Do you have a statement of                              Location of Delivery for:
Individual/Pastoral Education Plan?                Special Educational Needs (SEN)?
NO       YES       Details:                      NO        YES         Details:
                                                                                                           FS Delivery.................

                                                                                                           PLTS....................................

                                                                                                           Additional Learning.....................................


                                                                                                           Specialist Learning......................................

Do you have a disability/medical condition which may affect your participation in the programme?
                                                                                                           Project..............................................................
NO        YES        Details:

                                                                                                           Dates for work experience week ...............................................


                                                                                                           Exams
                                                                                                           Officer...................................HUB............................................Home......................................................


If you are 14-16 do you receive free     YES               NO                                            Group/ Cohort..................................................
school meals?



                                                                            Page 1                                                                                                                                                                   Page 6
Student and Parent Contract

Student responsibilities                                                                                  Student’s Name.....................................................................
Please read the following list of responsibilities and sign below to show that you agree with them.
                                                                                                          Date.......................................................................................
     1. I will attend and be punctual for all parts of my learning programme and timetabled
         activities.
     2. I will follow instructions given by the tutors and staff at the Learning Provider, ask for help
         when I am unsure about something and use my initiative.
     3. I will complete work assignments on time and to the best of my ability.                           Medical Questionnaire
     4. I will behave appropriately in the learning placement and on associated activities, and not
         disrupt the learning of others.                                                                  Are you in good health?               YES / NO
     5. I will care for and return all Learning Provider property
     6. I will accept and work within the Learning Provider’s requirements, particularly around           If ‘NO’ are you under medical treatment and reason: ________________________________________________
         Health and Safety, and wear protective clothing if necessary.
                                                                                                          Are you at present taking any medicines or tablets prescribed by your doctor?                            YES / NO
     7. I will attend any exams or assessments at the correct time and place.                             _________________
     8. I understand that I will be required to attend my course even when school is closed for
         INSET days.                                                                                      Have you had a major accident or illness? YES / NO Have you ever had a serious operation?                                 YES / NO
     9. I understand that I may be required to attend and move between Learning Providers,
         participate in external trips and visits as a part of the course.                                If ‘YES’ to either of the above, when and for what? _________________________________________________
     10. I understand that while at Plumpton College for learning provision I will be required to stay
         on College Premises and will not be directly supervised at break times.                          Are you awaiting any surgical operation or hospital appointment? YES / NO                              Details : ____________________
     11. I understand that if I fail to meet any of the above requirements, I may lose my placement.

Student Signature...................................................                                      Have you, or do you suffer from the following?

                                                                                                          Tuberculosis, Bronchitis, Asthma                              YES/NO               Blackouts, Epilepsy, Fits or Faints   YES/NO
Printed Name..........................................................
                                                                                                          Heart Disease or Disorder                                     YES/NO               Recurrent Stomach Trouble             YES/NO
Date........................................................................                              High Blood Pressure                                           YES/NO               Eye Disease or Visual Impairment      YES/NO
                                                                                                          Diabetes or Sugar Trouble                                     YES/NO               Do you wear glasses/contact lenses YES/NO
Parent/Carer Responsibilities
                                                                                                          Skin Disorders eg Eczema                                      YES/NO               Hearing Problems                      YES/NO
Please read the following list of responsibilities and sign below to show that you agree to them.         Any recurring Back or Neck Problems                           YES/NO               Nervous or Mental Disorder            YES/NO
                                                                                                          Allergies eg. Hay fever, drugs, plasters, dietary                    YES/NO
     1. I understand that I am responsible for the attendance and punctuality of the student on this      If yes please specify___________________________________________________________
        learning programme.
     2. I am responsible for the travel arrangements from home to the Learning Provider and back
        home each evening.                                                                                Have you any other health problems that have not already been mentioned?                               YES/NO
     3. I will notify the Home School immediately if there are any changes in medical circumstances
        and/or emergency contact numbers or direct to Plumpton College if no longer at school             If ‘YES’ details:
     4. I will notify the Learning Provider on each day of absence or in advance of a known               ____________________________________________________________________________
        absence. Any change to the normal arrangements for the day will be put in writing to the
        Learning Provider e.g. hospital appointment.
     5. I accept the need for responsible behaviour by the student and agree to support them in           Have you received the following injections/vaccinations?
        maintaining good behaviour during the course.                                                     (please confirm this with your doctor if you are unsure)
     6. I understand that the student may be required to attend and move between Learning
        Providers, participate in external visits and trips and give my permission for this.
                                                                                                          Full course Tetanus/Polio/Diphtheria                          YES/NO               Date : _____________________________
     7. I understand that the student may be required to leave the programme at any time should           MMR                                                           YES/NO               Date : _____________________________
        this contract be broken.                                                                          Meningitis                                                    YES/NO               Date : _____________________________
     8. I understand that whilst at Plumpton College for learning provision the student will be
        required to stay on the college premises and will not be directly supervised at break times.

Parent/Carer Signature.........................................................
                                                                                                                                                                                                                   Page 4
Printed Name........................................................................   Page 3
                                                                                                   Why have you chosen the Diploma and what are your expectations of the course?
                                                                                                   Detail any career aims or what you would like to do after this course.



Parent/Carer Consent

This section covers the necessary parental consent for a student working on one or more courses
of education outside the school at which they are registered.


                                                                                                   What are your interests/hobbies?
Photographs


With your permission, photographs may be taken of pupils whilst taking part in the
programme for the following purposes:

         Evidence of achievement                                                                  Declaration:
         Course promotional purposes
                                                                                                   I am applying for a place on the above course. If I am awarded a place on this course, I agree to
Please tick one of the following statements regarding the taking of such photographs.              keep to the programme provider’s code of conduct. I understand that if I breach this code,
                                                                                                   disciplinary action can be taken against me. I also consent to my personal details being used
                                                                                                   within this programme and the creation of a Unique Learner Number.
 I consent to photographs being taken of my son/daughter
                                                                                                   Student’s signature................................................................................Date.....................................
 I do not consent to photographs being taken of my son/daughter
                                                                                                   Section 3: Parent/carer’s consent
Data Protection
                                                                                                   Name of parent / carer (Print name):......................................................................................
I give my consent for appropriate and necessary data regarding my son/daughter to be held by and   Contact number......................................
shared between Learning Providers involved in the delivery of the Diploma.
                                                                                                   Please use this space to provide us with information about any special requirements your child has
Signature.........................................................
                                                                                                   and any other information you feel is relevant to their application:
Printed Name..................................................

Student’s Name...............................................

Date.................................................................


                                                                                                   Declaration:

                                                                                                   I support this application.
                                                                                                   If.......................................................(name of applicant) is offered a place on the programme, I
                                                                                                   consent to him/her taking part in all activities which form part of the course, including shared
                                                                                                   delivery of course between Learning Providers. I also acknowledge that whilst s/he is on the
                                                                                                   course, the school has sole responsibility with regard to Duty of Care. If s/he is educated other
                                                                                                   than at School then Duty of Care passes from the parent / carer to the training provider during
                                                                                                   training days.

                                                                                                   Signature........................................Name..................................................Date........................
                                                                                                   Parent/Carer (delete as appropriate)
                                                                          Page 5                                                                                                                                     Page 2

				
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