Application form

Below you will find our Adult Education application form which you may complete for all of our courses. Please note that enrolment onto the course can only be confirmed upon payment.

We will endeavour to contact you by phone or email within the next 24 hours (except at weekends or during school closure) to confirm receipt and and take payment details when relevant.

* = mandatory field

Personal Details

Please specify a title

Title ^*

Please enter a last name

Last Name ^*

Please enter your forename(s)

Forename(s) ^*

Please enter your address

Address Line 1 ^*

Address Line 2

Address Line 3

Please enter your town/city

Town / City ^*

Please enter your county

County ^*

Please enter your postcode

Postcode ^*

Please enter your date of birth

Date of Birth ^*

(dd-mm-yyyy)

Please indicate your gender

Gender ^*

Male Female

Contact Details

Please provide a daytime contact number

Tel No (Day) ^*

Tel No (Eve)

Please provide a contact email address

Email ^*

Course Details

Please select a course type

Course Type ^*

Please select a time

Day / Time

Please select at least one term

Terms Enrolled ^*

Autumn Spring Summer

Please list any other courses you are interested in here

Fee Remission

If claiming fee remission, please tick the box that describes your remission status

Job Seekers Allowance

Income Support

Working Tax Credit

Pension Credit

Housing Benefit

Burleigh Staff/Students

Council Tax Benefit

Trust Employees

65+ Unwaged

NUS

Unwaged Dependant

Other

Ethnic Status

Please help our equal opportunities monitoring by ticking ONE of the following boxes

Please tick only ONE box

Bangladeshi

Mixed - White and Asian

Indian

Mixed - White and Black African

Pakistani

Mixed - White and Black Caribbean

Any other Asian background

Mixed - any other mixed background

African

White - British

Caribbean

White - Irish

Any other Black background

White - any other White background

Chinese

Any Other

Disability Statement

Do you have a disability, learning difficulty, mobility or health problem which may affect your learning e.g deaf signer required, wheelchair access? If YES: Please give details below:

Please answer this statement

Disability ^*

Yes No

Comments

How did you find out about this course?

Please specify the website

Please specify

Burleigh Website

Other website (please specify)

Burleigh Brochure

Enrolled on a course at Burleigh

Echo Newspaper

Learndirect

Floodlight

Market Stall

The Beacon

Word of Mouth

Other (please specify)

Data Protection Act 1998

The information you provide will be held on computer and will only be accessible by authorised members of staff at this College. At no time will your personal information be passed to any external organisations for marketing or sales purposes. From time to time students are approached to take part in surveys by mail and phone, which are aimed at enabling the College to monitor performance, improve quality and plan future provision.

Tick this box if you do not wish to be contacted about courses or learning opportunities by post. The College may wish to contact you from time to time about courses, or learning opportunities relevant to you.

You must agree to this statement to submit your application

I agree to Burleigh College processing my personal data contained in this form, or any other data the college may obtain from me or other people. I agree to the processing of such data as detailed above, for any purposes connected with my studies, my health and safety whilst on the premises, or for any legitimate reason.