Gloucestershire County Council

Please select the area you are a resident of. *Required

Title

First Name *Required

Surname *Required

Sex *Required

DOB (You must be 18 or over) *Required

Search for address or postcode

Address *Required

Address 2

Address 3

Post Code *Required

Telephone Number *Required (Enter at least 1 of:Telephone Number , Mobile Number , Email)

Mobile Number *Required (Enter at least 1 of:Telephone Number , Mobile Number , Email)

Email Address *Required (Enter at least 1 of:Telephone Number , Mobile Number , Email)

Emergency Contact Name

Emergency Contact Telephone

Emergency Contact Relationship

Ethnicity *Required

Do you consider yourself to have a disability, learning difficulty and/or health problem? *Required Yes No

Qualifications already held (please select highest qualification) *Required

When did you attain this level of qualification? (If not known or no qualifications, use todays date) *Required

How did you hear about the course? *Required

Current employment status *Required

Length of Unemployment *Required

Are you currently in receipt of state benefits? Yes No

Please select the benefits you are in receipt of

Job Seekers Allowance - JSA

Employment and Support Allowance – ESA

Universal Credit

Other Benefits

National Insurance Number (Only required when applying for a qualification).

Do you require any further learning support – if yes please discuss this with your tutor? Yes No

Do you have an EHCP (Education and Health Care Plan)? Yes No

The information that you provide on this form will only be used to deliver the service you need or meet a requirement. Adult Education in Gloucestershire will contact you with information regarding your course. If you wish to opt in to contact for further marketing or surveys, please tick the boxes below. If you require further information, a detailed privacy notice can be found on our website at: adult-education-privacy-notice

Education and Skills Funding Agency (ESFA) privacy notice The ESFA is responsible for funding education and skills in England for children, young people, and adults. It is also responsible for delivery of key services in the education and skills sector in England including the Apprenticeship Service, the provision of information, advice and guidance through the National Careers Service and the Learning Record Service. We may use your personal information in the delivery of this work. We collect your personal information where the law allows it, or we have a legal obligation to do so. Your personal information is collected to enable us to carry out the functions of the DfE. A full version can be found at: Privacy notice for key stage 5 and adult education

Learning Records Service privacy notice The information you supply is used by the Learning Records Service(LRS). The LRS issues Unique Learner Numbers(ULN) and creates Personal Learning records across England, Wales and Northern Ireland, and is operated by the Education and Skills Funding Agency, an executive agency of the Department for Education(DfE).For more information about how your information is processed, and to access your Personal Learning Record, please refer to: lrs privacy notices

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Courses or Learning opportunities

Surveys and research

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I understand how my data will be used and confirm that the information supplied by me is correct. *Required Yes No

Course Application

This is an application and your place will be confirmed after enrolment, meanwhile a member of staff will be in contact to verify and complete the process once submitted. (Fees and concessions may apply).

There is a problem

Declarations

Course Application

This is an application and your place will be confirmed after enrolment, meanwhile a member of staff will be in contact to verify and complete the process once submitted. (Fees and concessions may apply).

Message

Please contact centre to check your eligibility.

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Privacy notice and Consent

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