Sixth Form External Application Form
Surname *
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Forename *
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Address *
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Postcode *
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Home Telephone Number *
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Student's Mobile Number
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Student's E-mail *
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Date of Birth *
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DD
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YYYY
Nationality *
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Parent/ Guardian 1
Title (Mr/ Mrs/ Miss etc) *
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Address *
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Mobile Number *
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Home Telephone Number *
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Parent/ Guardian 2
Title (Mr/ Mrs/ Miss etc)
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Address
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Mobile Number
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Home Telephone Number
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General Information
Medical Information
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Proposed Career/ Employment/ Aspirations
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Interests
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Proposed courses of study at Broughton Hall
Subject 1 *
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Subject 2 *
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Subject 3 *
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Reserve
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Education (current)
School/ College *
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Address *
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Post Code *
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Telephone Number *
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Head of Year 11 *
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Support
So we can support you, please tell us if you have:
If you selected any of the above, please provide details
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Student Bursary
You may be entitled to a student bursary – are you or your parents in receipt of:
We will contact you to discuss any support you may require. Any information provided will be treated in confidence.
Examination Results
We appreciate that any estimates maybe difficult to obtain due to the Covid-19 situation. However any information you may be able to provide will help to ensure you receive adequate guidance.
Please give details of ALL Subject's taken, if they were GCSE or Equivalent and Estimated Grades (or please state if grades have already been obtained)
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Personal Statement: Please include any further information about yourself to support your application (eg any hobbies, volunteering, clubs, interests)
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Reference – to be supplied by a referee at your current school
Attendance *
Punctuality *
Motivation *
Relationship with others *
Quality of Work *
Name of Referee at your current school who provided the above details *
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Referee's E-mail address
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