FE application form

Personal Details

Title

Surname/family name

First name

Correspondence address

Postcode

I'll enter this address manually

Address 1

Address 2

Town / City

Region

Postcode

Country

Telephone number

*with STD/international code if applicable

This is not my home address and telephone number

Please tell us your home address and telephone number.

Postcode

I'll enter this address manually

Address 1

Address 2

Town / City

Region

Postcode

Country

Telephone number

Email address

Mobile number

Which course would you like to study

First choice

Second choice

Would you like to study...

Full time

Part time

Additional personal details

Date of Birth

dd-mm-yyyy*

Gender

Male

Female

Nationality

Area of Permanent Residence

Country of Birth

Only students who will be aged under 18 on 1 September need to fill this section in.

Name of parent/guardian

Postcode

I'll enter this address manually

Address 1

Address 2

Town / City

Region

Postcode

Country

Daytime telephone number

Home telephone number

Secondary school(s)/college attended

Name of last school/college

Postcode

I'll enter this address manually

Address 1

Address 2

Town / City

Region

Postcode

Country

Telephone number

Attended from

Name of school/college

Postcode

I'll enter this address manually

Address 1

Address 2

Town / City

Region

Postcode

Country

Telephone number

Attended from

Qualifications

Already gained

Subject	Qualification	Grade	Date

Qualifications

To be taken

Subject	Qualification	Grade	Date

The University of Derby Buxton welcomes applications from students with learning difficulties, disabilities or medical conditions and aims to provide appropriate support for their specific needs. It is advisable to discuss any additional support needs you may have at an early stage. Any information given is confidential and will not affect your application.

I don't have a disability and I'm not aware of any additional support requirements for my studies

I have dyslexia

I am blind/partially sighted

I am deaf/have a hearing impairment

I am a wheelchair user/have mobility difficulties

I need personal care/support

I have mental health difficulties

I have an unseen disability eg diabetes, epilepsy, asthma, Aspergers Syndrome etc

I have a disability or require support in an area not listed above eg numeracy, language difficulty etc.

How did you hear about the course

School open day	Careers convention at School
College open day	Careers Service
Careers teacher or other teacher from school	Visiting or telephoning the college
Friend or family	Newspaper or other advertisement

Other

Do you have any unspent criminal convictions (excluding motoring offences)?

Yes

*If you're applying for a course in teaching, health, social work or a course which involves working with children or vulnerable adults, you must tell us about any criminal convictions, including spent sentences and cautions (including verbal cautions) and bindover orders. For these courses you may need an ‘enhanced disclosure document’ from the Criminal Records Bureau or the Scottish Criminal Record Office Disclosure Service.

Reference

Not to be filled in by applicants currently at school.

Name of Referee

Position/occupation

Postcode

I'll enter this address manually

Daytime telephone number

The information you give us on this form will only be used by our University. We may use it to send you reminders or updates about things at Buxton. We won't give your details to anyone outside the University.