Applicant's name forenames: surname: Home address. Student for correspondence. Telephone no Mobile no. Name(s) of parent(s) or guardian

Please stick photograph here SHOTTERY SIXTH FORM APPLICATION FORM SEPTEMBER 2017 Please fill in this form as fully as you can and sign and date the D...
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SHOTTERY SIXTH FORM APPLICATION FORM SEPTEMBER 2017 Please fill in this form as fully as you can and sign and date the Declaration. A parent/carer needs to countersign your signature. Please use capital letters and ensure that we have your current direct email address as we will correspond with you via email. This form needs to be submitted along with your personal statement by Friday 6th January 2017.

Applicant's name

Home address





_________________________________________________________________ __________________________________________________________________

Post code _____________ Telephone no

Student email for correspondence ___________________________


Name(s) of parent(s) or guardian Applicant’s date of birth:

Mobile no



Date ________ Month _____________ Year ______

A-level subjects you wish to study in the sixth form – please use blocking grid for a full list of subjects available Option Choice


Block A Block B Block C Wider curriculum


Business & Enterprise

please circle area of interest



Creative Writing

Practical Maths Further Maths





Other – please state any additional area you would be interested in:

For our information only, if your preferred combination of subjects is not possible within our option blocks, please state here your preferred three A-level subjects in order of preference. 1



Declaration: I confirm that to the best of my knowledge the information given in this form is correct and complete. Student signature: ________________________________

Date: _________________________

Parent/Carer approval: I support this application by my daughter Signature: ____________________ Parent/Carer email: ___________________________________

Education from age 11 starting with your present school: Name(s) & address of school(s)

from month year




Type of present school *Comprehensive/Grammar/Independent School etc (*Please delete as appropriate) Name of present Headteacher


School telephone number _________________________________________ School email _____________________________________________________________________ Date/s not available to discuss application: _________________________________________ Academic studies Please list subjects in alphabetical order. Group together all subjects being taken at one sitting. Level


Exam Board

Month/ Year

Predicted Grade

Actual Grade

Other qualifications eg music, drama, dance certificates

Extra-curricular activities at school (eg representation in sporting achievements/events, choir, orchestra, drama, student council etc.)

Interests/hobbies (inside and outside school)

Positions of responsibility (inside and outside school)

Details/dates of work experience Please give details of any work experience placements, voluntary work or weekend jobs Experience

Approximate dates (from - to)

Details/dates of residential experience, field courses, overseas visits (school)

Present career / post 18 plans / interests

Do you require any special arrangements to help you access learning, eg. coloured paper, additional time in exams, access to a lift etc. ______________________________________________________________________________ _______________________________________________________________________________ Please note that this information will not affect your offer of a place, but will enable us to prepare any support that you may need.

PART TWO: School reference: To be completed by Headteacher/Head of Year Unique Candidate Identifier Unique Learner Number Please tick the relevant box





Full attendance (>95%) Punctual Reliable Requires minimum supervision Communicates effectively in speech Communicates effectively in writing Works hard Works well with others Sociable Well organised Resilient Perseveres Confident Helpful and co-operative Adaptable Please comment on any achievements, characteristics, or circumstances of which we should be aware in relation to the candidate, and also the candidate’s suitability for academic A-level courses in a selective sixth form. Please also inform us of any additional learning needs the student may have.

Name: Position:

Signature: Date:

School Stamp This form should reach us as soon as possible but no later than 6th January 2017

PART TWO: School reference (cont’d): To be completed by Headteacher or Head of Year/House Please provide information of all exams taken already or to be taken next summer. Level (GCSE, AS etc)

Exam Board

Subject English Language Maths

*if different from target grade

Date taken/ to be taken

Achieved grade

Target grade

Predicted grade*

Mock grade

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