Tel: 01284 705031

Fax after 6pm:01284 705031

Course details: Which course do you wish to enrol on?

Marketing: Where did you find out about this course?

Personal details:

SURNAME/FAMILY NAME:

ALL FORENAME(S) IN FULL:

TITLE: E.G. Mr, Mrs, Miss:                          DATE OF BIRTH:                                  MALE/FEMALE

COUNTRY OF BIRTH:

YOUR NATIONALITY:

Have you been a permanent resident in the UK/European Union for the past 3 years?

Yes No

Permanent Home Address

Post Code

 Home Tel no.:

Daytime tel. no.:

 e-mail address:

Name of next of kin:                                                Contact tel. no:

Do you consider yourself to have any additional learning needs/disability? (Please tick)

Yes No

Do you require assistance to evacuate the building in the event of an emergency?

Yes No

PLEASE TICK THE DESCRIBTION THAT MOST ADEQUATELY DESCRIBES YOUR GROUP:

Asian or Asian British - Bangladeshi Asian or Asian British - Indian

Asian or Asian British - Pakistani Asian or Asian British - any other Asian background

Black or Black British - African Black or Black British - Caribbean

Black or Black British - any other Black background Chinese

Mixed - White and Asian Mixed - White and Black African

Mixed - White and Black Caribbean Mixed - any other Mixed background

White - British White - Irish

White - any other White background any other

Not known / not provided

Please enter the name of school / college attended last year (if applicable)

NAME & ADDRESS OF CURRENT EMPLOYER (IF EMPLOYED) Employer Name: Employer Address: Postcode: Contact name: Position: Telephone number:

IF YOU ARE EMPLOYED, HAS YOUR EMPLOYER RELEASED YOU FROM WORK TO ATTEND THE COURSE? YES NO

ARE YOU AGED 19+?

Do you have any of the following qualifications? 5 GCSE's grade C or above? First Diploma (BTEC) NVQ Level 2 Higher Qualification

FEE DETAILS TO BE COMPLETED BY THE STUDENT STUDENT TO PAY: CASH CHEQUE

IF YOU ARE UNDER 18 AT THE START OF THE COURSE THE SCHOOL RESERVES THE RIGHT TO REMAIN IN CONTACT WITH YOUR PARENTS/GUARDIAN UNTIL YOU REACH THE AGE OF 18 YEARS.

DECLARATION I agree that I have received the adequate guidance and support and confirm that the programme of study suits my learning needs, which may vary and be complemented as my studies progress. I understand that admission to this course may be subject to satisfactory academic attainment. If accepted as a student, I acknowledge receipt of the regulations of GeeCol Wellness Training Centre and agree to abide by them. (Policies found on www.geecolwellness.co.uk) STUDENT SIGNATURE:                                                                DATE: