1. Sixth Form Application for September 2017
For Students born before 31 August (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 • •

2. 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 • •

3. 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 • •

4. 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 • •

5. 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 to 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 • •