Enrolment Form & Learning Agreement 17/18 Standard Code: 1. Personal Details Title Gender? Surname Forename Previous Family Name Known as Date of Birth Age on 31st Aug 2017 NationalIN Address Details First Line of Your Address Town County PostCode Email Tel Mobile Tel Home 1.1 Emergency Contact Details Name Email Address Relationship Mobile Number Home Number Name Email Address Relationship Mobile Number Home Number 2. Ethnic Origin Ethnic Origin 3. Nationality Please state your Nationality e.g. British. Which Country Do You Normally Live In? Have you been a resident in the UK/EEA for the past 3 years? Date of Entry to the UK Was this for the purpose of education? Are you a refugee or asylum seeker? Note: If you haven't always resided in the UK we will need to see your passport at enrolment Passport Number Issue Date 4. Disabilities & Learning Difficulties Do you consider yourself to have a learning difficulty and/or disability and/or health problem? Do you think that you may need additional support whilst on your training programme? 4.1 If you have more than one learning difficulty and/or disability please state which is your primary Please type in the letter "Y" for yes in the box most applicable. Visual Impairment Hearing Impairment Disability Affecting Mobility Profound Complex Disabilities Social and Emotional Difficulties Mental Health Difficulty Moderate Learning Difficulty Severe Learning Difficulty Dyslexia Dyscalculia Autism Spectrum Disorder Asperger's Syndrome Temporary Disability after illness Speech, language & communication needs Other physical disability Other Specific Learning Difficulty Other Medical Condition Other Learning Difficulty Other Disabilities Prefer not to say Standard Code: 5. Prior Attainment Level Entry Level Level 1 Full Level 2 Full Level 3 Level 4 Level 5 Level 6 Level 7 Other Qualifications / Not Known Prefer not to say 5.1 Prior Attainment Enlish & Maths GCSE X Or U or no previous qualifications Functional Skills Entry Level Functional Skills Entry Level 2 Functional Skills Entry Level 3 Functional Skills Entry Level 1* Functional Skills Entry Level 2 GCSE E-G GCSE D GCSE A* - C English Maths Please put the letter "Y" for yes to the one that applies to you. I have exemptions for my level 1 functional skills elements and wish to complete my Level 2's I have exemptions for my level 1 functional skills elements and do not wish to complete my Level 2's 6. Household Situation No Household member is in employment and the household includes one or more dependant children No Household member is in employment and the household does not include any dependant children Learner lives in a single adult household and with dependant children Prefer not to say None of the HHS1, HHS2, or HHS3 applies 6.1 Your Employment/Education Status Prior To Starting Your Course - A. Employed Up to 3 Months 4-6 Months 7-12 Months 12+ Months 6.1 Your Employment/Education Status Prior To Starting Your Course - B. Employed Less than 16 Hours a week 16-19 Months a week 20-29 Hours a week 30 Hours and above a week 6.1 Your Employment/Education Status Prior To Starting Your Course - A. Unemployed Less than 6 Months 6-11 Months 12-23 Months 24-35 Months Over 36 Months 6.1 Your Employment/Education Status Prior To Starting Your Course - B. Unemployed In receipt of JSA In receipt of ESA Other Benefits Universal Credits 6.1 Your Employment/Education Status Prior To Starting Your Course - A. Other Full-time education or training Self Employed Other 7. Your Choice Of Course (This will be filled out by ESP) 8. Employment Details Company Name Address ERN Employment Start Date 9. Self Declaration If you are enrolling on a course which is identified as your first full level 2 or 3 or entry level 1 to level 1 please tick; I am aged 19-23 and enrolling on a entry level 1/2/3 or level programme (not ESOL), English or Maths) and do not currently hold a Qualification at Level 2 or above I am enrolling on any first full level 2 or below qualification and do not currently hold a qualification at level 2 or above I am enrolling on functional skills English & Maths course or GCSE Maths/English and do not hold grade C or above in the subject I am aged 19-23 and enrolling on my first full leve 3 or level 4 qualification and do not currently hold a qualification level 3 or above I am enrolling on a Level 2 or below qualification and am undertaking this course to assist my entry in to employment. I am currently in recipt of: JSA, ESA or Universal Credit OR Means Tested Other State Benefit other than JSA, ESA or Universal Credit I am enrolling enrolling on my first full Level 3 qualification, do not currently hold a qualification at Level 3 or above and was a member of the British Armed Forces within the last 10 Years and one of the following applies to me; I served a minimum or 4 years I completed basic training but server less than 4 years due to medical discharge througbh injury in active service I Confirm that the above statement is true; Learner Name [text 9name] Learner Signature [text 9sig] Date [text 9date] 10. PAYMENT BY EMPLOYER – NON LEVY FUNDED LEARNERS ONLY As part of the new Levy funding guidelines 01/05/2017, if you are a non levy paying employer you will share the cost of training and assessment with the government, this is called “co-investment”, you (the employer) will pay 10% towards the cost of training while the government will pay the remaining 90% up to the maximum funding band (for more information please visit https://www.gov.uk/government/publications/apprenticeship-levy-how-it-will-work/apprenticeship-levy-how-it-will-work#non-levy-paying- employers) I am a non levy paying employer and agree to pay the 10% towards this learners training and assessment costs Employers full name and invoice address: Postcode Telephone Number Email Contact Name Signature Date Employer purchase order number SAFEGUARDING CHILDREN, YOUNG PEOPLE AND VULNERABLE ADULTS ESP is keen to support all students to help them succeed. For some careers you will need to declare all criminal convictions including those that are spent. We ask that you declare all unspent criminal convictions, doing this will not necessarily stop you being offered a place on the course. If you are unsure on what to declare then please seek advice from our student advisor or ask a careers advisor at the national careers service at https://nationalcareersservice.direct.gov.uk. I have unspent criminal convication Yes No If you have declared that you have an unspent criminal conviction you will receive a letter with an attached form. You will have 10 days to return the form to ESP who will review your disclosure and will inform you of any actions we may take. They may ask you to come in for an interview to further discuss your disclosure. Please note that failing to complete this section or providing false information may lead to your application/enrolment being withdrawn. LEARNING AGREEMENT Opportunities for regular assessment, review of your progress and recording of your achievements Opportunities for individual advice, guidance and support at all stages of your learning Reasonable access to appropriate facilities , resources and equipment Agreed learning and learner support Opportunities to comment on your learning programme An action plan to support your progress to further/higher education and training or employment Equality of opportunity IN SIGNING THIS LEARNING AGREEMENT YOU ARE; That you have received appropriate advice and guidance on your choice of programme to assess your suitability in accordance with ESP procedures To accept responsibilities for your own learning and to review your progress with the support of your tutor(s). To attend all required activities regularly and punctually and to account for any absences . To take responsibility for maintaining an acceptable standard of behaviour whilst engaged in activities associated with ESP. To complete all of your work to the best of your ability an d within specified deadlines , as required by your programme. To follow and respect published policies, rules, regulations, copies of which are available That the information on this enrolment form/learning agreement is correct and that you will inform ESP of any future changes. To look after all resources during use and make sure they are properly issued and returned on time To comply with copyright laws and licenses regarding to copying of resources including all DVD’S and audio If you are under the age of 19 – on the 31st August 2017, we will share relevant information, all academic year, about your studies with your parent/guardian. We will share information about your studies if your employer is paying your fees . EXAMINATIONS AND REGISTRATIONS All students are themselves wholly responsible for their entry to examinations. Notices giving closing dates for the receipt of all examination entries are displayed and students should carefully observe the information thereon. Alternative arrangements cannot be made for students on holiday during examination periods. DATA PROTECTION & YOUR PERSONAL INFORMATION – How we use your personal information By providing the information contained in the enrolment form you consent to ESP holding and processing the information as set out in our registration. As part of audit and compliance ESP may be required to share your details with third parties however ESP will ensure that we comply with the general data protection regulation at all times. It will also be used by the Education and Skills Funding Agency (ESFA) an exclusive agency of the department for education (DFE) for statistical analysis and to issue you with a unique learner number (ULN), and to create your personal learning record. For more information about how your information is processed and shared refer to the extended privacy notices on Gov.uk Https://www.gov.uk/government/publications/lrs-privacy-notices Https://www.gov.uk/government/publications/sfa-privacy-notices You can opt out of contact by the ESP & ESFA by ticking any of the following boxes; if you do not wish to be contacted; About New Courses: About New Courses Surveys and research By Post By Phone Learning Opportunities Surveys and research By Post By Phone Learner Declaration I confirm that the details I have given on all sides of this form are correct. I have received enough information about the courses(s) for which I am enrolling to make an informed choice and I am aware of the range or support that is available to help my learning. Learner Name Signature Date End Employer Name (Apprenticeship Only) Job Role Signature Date Any Problems please use the contact button on the top to get in contact with us.