Educational Stages and Palmer Catholic Academy

THE PALMER CATHOLIC ACADEMY Aldborough Road South, Seven Kings, Ilford, Essex, IG3 8EU Tel: 020 8590 3808 Fax: 020 8597 5119
Email: office@thepalmercatholicacademy.org.uk Website: the palmercatholicacademy.org

APPLICATION FOR ADMISSION TO THE SIXTH FORM – SEPTEMBER 2012 Please complete Sections 1 to 4 and ask your Head of Year to complete Section 5
SECTION 1 Surname ……………………………………………………… Forename(s)…………………………………………………. Date of birth …………………………….. male / female

Religion ………………………………………(Roman Catholic applicants must include a priest reference form) Address ……………………………………………………………………………………………………. ……………………………………………………………Post Code……………………………………… Resident in the London Borough of ……………………………………………………………………… Home telephone number ………………………… Names of Parents / Carers ………………………………………………………….. SECTION 2 EDUCATION: Current School…………………………………………………………… Telephone ……………………

Any Other Secondary School…………………………………………………Dates ……………………….. Primary School …………………………………………………………... Year left ……………………

(please ensure this section is fully completed)
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SECTION 3

SUBJECT CHOICES SEPTEMBER 2012

All courses are described in the Booklet accompanying the Prospectus and are subject to numbers and staffing. You must ensure that you are fully aware of the requirements of each course before completing this section. Please indicate by placing a tick next to the four A Levels subjects you wish to study in Year 12.

SUBJECT
APPLIED SCIENCE ACCOUNTING ART BIOLOGY BUSINESS STUDIES APPLIED CHEMISTRY DRAMA & THEATRE STUDIES ENGLISH LITERATURE FRENCH GEOGRAPHY GOVERNMENT & POLITICS HEALTH & SOCIAL CARE HISTORY INFORMATION TECHNOLOGY MATHEMATICS FURTHER MATHEMATICS PHYSICS PSYCHOLOGY PHYSICAL EDUCATION RELIGIOUS PHILOSOPHY & ETHICS SOCIOLOGY

PLEASE TICK 4

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SECTION 4
SUBJECT

PUBLIC EXAMINATIONS TO BE TAKEN:
PREDICTED GRADE GCSE RESULT (please leave blank)

PLEASE INDICATE HIGHER OR INTERMEDIATE

Any GCSE examination(s) already passed: Subject ……………………………………… Grade ……… Date ………………… Subject …………………………………… Grade ……… Date …………………

Have you applied to any other Sixth Form or College? If YES, please give details: ………………………………………………………………………………………………………………………… Do you have a part/time job? If YES, please give name of employer and number of hours worked: …………………………………………………………………………………………………………………………

SIGNATURE OF STUDENT ……………………………………………………………….

SIGNATURE OF PARENT / CARER ………………………………………………………

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SECTION 5

TO BE COMPLETED BY APPLICANT’S HEAD OF YEAR.

IMPORTANT: IF YOUR SCHOOL IS SUPPLYING A SEPARATE REFERENCE THIS MUST INCLUDE YOUR UCI AND UPN (see below)
ATTENDANCE PERCENTAGE PUNCTUALITY PERCENTAGE
Excellent Poor

A Attitude to work Attitude to staff Reliability Initiative Perseverance Meeting deadlines Honesty Ability to work alone Ability to work with others Hardworking

B

C

D

E

PLEASE COMMENT ON THE SUITABILITY OF THE APPLICANT: ……………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………

DO THE ESTIMATED GRADES GIVEN REPRESENT FAIR ASSESSMENT OF LIKELY ACHIEVEMENT? YES / NO
Student’s U.C.I.

(Unique Candidate Identifier for exam entries)
Student’s U.P.N.

(Unique Pupil Number on student database)

Signed ………………………………………………… Name ………………………………………………… Position ………………………………………………… Contact No: ……………………………………………..

Please apply your school stamp here to verify this reference

UCI AND UPN NUMBERS MUST BE INCLUDED

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DO NOT FILL IN THIS SECTION. IT WILL BE COMPLETED DURING YOUR INTERVIEW
BLOCK A BLOCK B BLOCK C BLOCK D

Name of applicant …………………………………………………………………………………………………………………………. Interests ……………………………………………………………………………………………………………………………………… Intended career ……………………………………………………………………………………………………………………………… Comments on student ........................................................................................................................ ………………………………………………………………………………………………………………………………………………………

Signature of interviewer ……………………………………………………Date …………………………

_________________________________________________________ SCHOOL USE ONLY:
September 2012 – final choice of subjects:
BLOCK A BLOCK B BLOCK C BLOCK D

GCSE ENGLISH RESIT

GCSE MATHS RESIT

Received with thanks the sum of: ……………………Enrolment Fee
Cheques to be made payable to The Palmer Catholic Academy

Signatures:

Sixth Form Tutor ………………………………………… Head of Sixth Form / Head of Year 12 …………………………………………..

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September 2013
Block
A B C D

Exam results in Yr 12: Modules

Subject

AS Grade

OTHER COURSES A B C D OTHER

LEVEL

RESULT

COURSES IN YR 12 IF RESITTING :

Enrolment Fee £ ……………… paid

Signed…………………………………………… Sixth Form Tutor ……………………………………………. Head of Sixth Form/Head of Year 12

COURSES IN YR 13:

A

B C D OTHER

Enrolment Fee £ ……………… paid Signed…………………………………………… Sixth Form Tutor ……………………………………………. Head of Sixth Form/Head of Year 13

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