0800 783 6095
Your Family Name
Your First Name(s)
Date of Birth
Have you lived permanently in the UK/EU for the last three
years for purposes other than study?
Home Tel. No
Mobile Tel. No
Unique Learner Number (ULN)
How did you find out about Dudley Sixth?
Please use the space below to provide additional information
about yourself, e.g. your interests/hobbies, your future
Which A Levels do you want to study?
At Dudley Sixth we can provide additional help to many
students. Please let us know if you are entitled by selecting
from the options below or in the space provided.
Disability affecting mobility
Other physical disability
Other medical condition (e.g., epilepsy, asthma, diabetes)
Mental health difficulty
Temporary disability after illness (e.g., post-viral) or accident
Profound complex disabilities
Moderate learning difficulty
Severe learning difficulty
Other specific learning difficulty
Autism spectrum disorder
Multiple learning difficulties
Do you require any assistance when you attend an interview at
Dudley Sixth e.g. interpreter, wheelchair access?
Please select your ethnic origin:
English / Welsh / Scottish / Northern Irish / British
Gypsy or Irish Traveller
Any Other White background
Mixed / Multiple ethnic group
White and Black Caribbean
White and Black African
White and Asian
Any Other Mixed / multiple ethnic background
Asian / Asian British
Any other Asian background
Black / African / Caribbean / Black British
Any other Black / African / Caribbean background
Other ethnic group
Any other ethnic group
Name of referee
Date attended from
Dudley College of Technology is committed to protecting your privacy and personal data. The data captured on this form will be used for processing your application / enquiry and we may contact you using the information provided. The college will not share this information with any other organisation at this stage. For more information on what data we collect, how we use it, and your rights under data protection law please visit dudleycol.ac.uk/privacy.
I consent to the data captured on this form to be used for informing me about college courses, events or learning opportunities (please tick box).