Sixth Form Application (External Applicants) Surname (required) Forenames (required) DoB (DD/MM/YYYY) Email Address (required) Recent Photograph of Yourself (required) Home Address (required) Current School (required) A Level / BTEC subject choices I would like to join the Extra Curricular Football Academy: YesNo Please list your personal qualities, hobbies and interests (required) Please tell us your career aspirations after you have completed your sixth form studies (required) Please list the schools you have attended since the age of 11 School 1 School: Date Started: Date Finished: School 2 School: Date Started: Date Finished: School 3 School: Date Started: Date Finished: Please list the qualifications you have already attained: Qualification 1 Subject: Level e.g. GCSE: Year Taken: Result: Qualification 2 Subject: Level e.g. GCSE: Year Taken: Result: Qualification 3 Subject: Level e.g. GCSE: Year Taken: Result: Qualification 4 Subject: Level e.g. GCSE: Year Taken: Result: Qualifications to be completed this year (required) Are you receiving any additional support e.g. extra help with your reading or writing or help in the classroom taking notes? YesNo Do you consider yourself to have a disability? YesNo If yes, please tick any disability which applies to you, provide brief details below: Partially sighted Blind Hearing impaired Deaf Physical Disability, wheelchair user Physical Disability, non wheelchair user Learning Difficulty Other Do you have any health problems which could affect your learning? YesNo If yes please give brief details: I declare that the information given on this form is correct and that I agree to abide by the Helena Romanes Sixth Form Centre rules and regulations. The approval of a parent or guardian is required if the applicant is under 18 years of age on September 1st 2019. By ticking this box, you confirm that you have discussed this application with your parent/guardian Parent/Guardian Name Address Contact Number Please give details of any other relative who should receive Progress Checks, Reports etc. Please state name and address and relation to student Privacy Notice By ticking this box, you confirm that you have read the Privacy Notice If you have any queries please contact Mrs Wright (Head of Sixth Form) on 01371 878636 or via email – email@example.com The deadline for completed Sixth Form Applications is Friday 14th December 2018.