Application for Year 12 2017/18

About you

Student's first name* Student's last name* Student's email address*

Would you like to be contacted by email?*YesNo

Student's gender*MaleFemale

Student's date of birth (DD/MM/YYYY)* Student's address - line 1* Student's address - line 2 Student's address - town/city* Student's address - postcode* Student's home telephone number (no spaces please)* Student's mobile number (no spaces please) Parent/guardian contact email address* Parent/guardian contact telephone number (no spaces please)*

Emergency contact details

Emergency contact name* Relationship to you* Contact address - line 1* Contact address - line 2 Contact address - town/city* Contact address - postcode* Contact phone number (no spaces please)* Contact email address*

Your subject options

Please select one of the following qualification options:*BTEC Extended Diploma in Engineering (no additional A-levels needed below)BTEC Extended Diploma in Computing (no additional A-levels needed below)BTEC Extended Certificate in Engineering (select two additional A-levels below)BTEC Extended Certificate in Computing (select two additional A-levels below)BTEC Diploma in Engineering (select one additional A-level below)BTEC Diploma in Computing (select one additional A-level below)Three A-levels (select three A-levels below)

Please select the number of A-level options specified in your answer above, plus a reserve option.

A-level option 1* A-level option 2* A-level option 3* A-level reserve option*

Your previous education

	Subject and level (e.g. GCSE IT)	Year	Predicted result	Actual result (if applicable)

Your future plans

Please outline your reasons for wanting to attend the UTC and career aspirations:*

Extra support for you

We provide a range of support for learners with learning difficulties, disabilities, medical and language support needs. This includes, and is not restricted to, support for mobility difficulties, visual impairments, deaf or hard of hearing, mental health difficulties, medial conditions such as epilepsy and specific learning difficulties such as dyslexia.

If you would like a confidential interview, please tick this box

How would you prefer to be contacted?EmailPostPhone

Where did you find out about us?

Information given on this form is personal data and is therefore subject to Data Protection Act 1998. Information you provide on this form may be passed to relevant educational agencies and Connexions, which are registered under the Data Protection Act 1998. Further information about data confidentiality is available upon request from student services. The UTC or Connexions may contact you to provide details and advise on further study and career opportunities.

If you do not wish to receive such information, please tick this box

Year*

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