Sixth Form Application for September 2017 For Students born between 1 September 2000 to 31 August 2001 (Current Year 11) PERSONAL DETAILS Surname   Forename Gender Male Female Date of Birth Address Home Phone Number Mobile Number Parent(s) Name Current School Date Started If Moseley, state house Form What type of courses are you interested in? GCSE & Level 2 courses BTEC National (Level 3) A Level Combination of BTEC National & A Level Which subjects would you like to study? Do you have a learning difficulty/disability and/or health problem(s)? Yes □ No □   If YES give details: ………………………………....................................................... Is the above likely to affect your learning?                          Yes □ No □ Do you have any support at school to assist you in your learning?            Yes □ No □ Do you have any evidence that you had extra support in your exams?     Yes □ No □ If you think that you qualify for support in your exams, we will need to see the written evidence from your present/previous school Moseley School, Wake Green Road, B13 9UU • 0121 566 6444 • enquiries@moseley.bham.sch.uk

Level: GCSE / BTEC / Other Grade Estimated Grade Achieved What subjects are you currently studying? Please include any GCSEs already achieved. Subject & Exam Board Level: GCSE / BTEC / Other Grade Estimated Grade Achieved What are your career ambitions for the future? How does your choice of subjects link in with this?   Moseley School, Wake Green Road, B13 9UU • 0121 566 6444 • enquiries@moseley.bham.sch.uk

Give details about any work experience you have had   Describe your interests and hobbies   Explain why you would like to study at Moseley School Sixth Form   Moseley School, Wake Green Road, B13 9UU • 0121 566 6444 • enquiries@moseley.bham.sch.uk

The student below has applied to us for a place in Sixth Form and has indicated that you are willing to supply a reference. Moseley School would like to take the opportunity to thank you for your assistance. Current School   Name of Referee Position Date Surname   Forename DOB Please confirm the dates between which the student attended the school/college Start Date Leave Date Attendance Excellent Good Satisfactory Below Expectation Poor Very Poor ☐ Punctuality Excellent Good Satisfactory Below Expectation Poor Very Poor ☐ Attitude to Study Excellent Good Satisfactory Below Expectation Poor Very Poor ☐ Determination Excellent Good Satisfactory Below Expectation Poor Very Poor ☐ Maturity Excellent Good Satisfactory Below Expectation Poor Very Poor ☐ Aptitude for Advanced Level Study Excellent Good Satisfactory Below Expectation Poor Very Poor ☐ Moseley School, Wake Green Road, B13 9UU • 0121 566 6444 • enquiries@moseley.bham.sch.uk

Moseley School & Sixth Form Suitability for Chosen Courses Excellent Good Satisfactory Below Expectation Poor Very Poor ☐ Other information (for example, health, specific learning difficulties, requirements for exams)   Thank you for providing a reference for this applicant. Please return this form by email to enquiry@moseley.bham.sch.uk. The information on this form will be held by us under the terms of the Data Protection Act and used for managing the application process, planning our provision and monitoring equality of opportunity for all of our applicants.   Moseley School & Sixth Form Moseley School, Wake Green Road, B13 9UU • 0121 566 6444 • enquiries@moseley.bham.sch.uk