Sixth Form Application for September 2017 For Students born before 31 August 2000 (Current Year 12 or above) PERSONAL DETAILS Surname   Forename Gender Male Female Date of Birth Address Home Phone Number Mobile Number Parent(s) Name Current School / College Date Started If you are not currently studying full time, please explain why What type of course 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

Please give details of your GCSE and Level 2 qualifications What subjects are you currently studying? Please include any Level 3 qualifications already achieved. Subject Exam Board Level: A Level / BTEC National / BTEC First Grade Estimated Grade Achieved Please give details of your GCSE and Level 2 qualifications Subject Exam Board Level: GCSE / BTEC / Other Grade Achieved Moseley School, Wake Green Road, B13 9UU • 0121 566 6444 • enquiries@moseley.bham.sch.uk

What are your career ambitions for the future? How does your choice of subjects link in with this?   Describe your interests and hobbies and give details about any work experience you have had   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