CAS - Distance Learning Application Referral Form

This form is for use for referrals from CAS only.

PLEASE NOTE: 19-23 year olds applying for a distance learning course should have 5 GCSE’s or a full level 2 qualification to study.

PERSONAL DETAILS

Title(*)

BrDrMastMissMrMrsMsMxProfRevdSr

First Name(s)(*)

Please let us know your first name.

Surname(*)

Please let us know your surname.

Date of Birth (*)

Day01020304050607080910111213141516171819202122232425262728293031 MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Year20052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Please enter your date of birth.

Email(*)

Please let us know your email address.

Sex (as stated on your birth certificate) (*)

Female

Male

Please let us know your sex (as stated on your birth certificate).

Gender that you identify with (*)

Please select from...MaleFemaleNon-BinaryTransgender (Male)Transgender (Female)Gender FluidOtherPrefer Not to Say

Please let us know what gender you identify with.

YOUR ADDRESS

House Number/Name and Road Name (*)

Please enter your House Number/Name and Road Name

Address Line 2

Invalid Input

Town/City (*)

Please enter the Town/City from your address.

County

Invalid Input

Postcode (*)

Please submit your postcode.

IMPORTANT: Please double check your address is correct before submitting your application.

COURSE CHOICE

Please select which distance learning course you are interested in studying using the link below:

Please select from...Level 2 Certificate in Awareness of Mental Health ProblemsLevel 2 Certificate in Common Health ConditionsLevel 2 Certificate in Counselling SkillsLevel 2 Certificate in Customer ServiceLevel 2 Certificate in Customer Service for Health and Social Care SettingsLevel 2 Certificate in Equality and DiversityLevel 2 Certificate in Falls Prevention AwarenessLevel 2 Certificate in Information, Advice or GuidanceLevel 2 Certificate in Preparing to Work in Adult Social CareLevel 2 Certificate in Principles of Team LeadingLevel 2 Certificate in Principles of Working with Individuals with Learning DisabilitiesLevel 2 Certificate in the Principles of Care PlanningLevel 2 Certificate in the Principles of Dementia CareLevel 2 Certificate in the Principles of End of Life CareLevel 2 Certificate in the Principles of the Prevention and Control of Infection in Health Care SettingsLevel 2 Certificate in Understanding AutismLevel 2 Certificate in Understanding Behaviour that ChallengesLevel 2 Certificate In Understanding Cancer SupportLevel 2 Certificate in Understanding Children and Young People's Mental HealthLevel 2 Certificate in Understanding Common Childhood IllnessesLevel 2 Certificate in Understanding Dignity and Safeguarding in Adult Health and Social CareLevel 2 Certificate in Understanding Mental Health First Aid and Mental Health Advocacy in the WorkplaceLevel 2 Certificate in Understanding Mental Health in the Early YearsLevel 2 Certificate in Understanding Nutrition and HealthLevel 2 Certificate in Understanding Safeguarding and PreventLevel 2 Certificate in Understanding Specific Learning DifficultiesLevel 2 Certificate in Understanding the Care and Management of DiabetesLevel 2 Certificate in Understanding the Safe Handling of Medication in Health and Social CareLevel 2 Certificate Introducing Caring for Children and Young PeopleLevel 2 Course in Understanding Climate Change and Environmental AwarenessLevel 3 Certificate in Preparing to Work in Adult Social Care Invalid Input

HEALTH, DISABILITY AND ADDITIONAL LEARNING SUPPORT

Do you have anxiety, a disability, medical condition, learning difficulty, dyslexia, dyspraxia, ADHD, mobility difficulties, autistic spectrum disorder mental health issues, any other health impairment or disability or, are you deaf, hard of hearing, blind or visually impaired? (*)

Yes No

Please let us know if you have any health, disability or additional learning support needs.

Please let us know a little bit more about your disability, learning difficulty or health conditions which may affect your course:

Please choose from the following options:Asperger's syndromeAutism spectrum disorderDisability affecting mobilityDyscalculiaDyslexiaHearing impairmentMental health difficultyModerate learning difficultyProfound complex disabilitiesSevere learning difficultySocial and emotional difficultiesSpeech, Language and Communication NeedsTemporary disability after illness (for example post-viral) or accidentVision impairmentOther disabilityOther learning difficultyOther medical condition (for example epilepsy, asthma, diabetes)Other physical disabilityOther specific learning difficulty (e.g. Dyspraxia)

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Please use this box if you need to add any additional disabilities, difficulties or conditions:

Please choose from the following options:Asperger's syndromeAutism spectrum disorderDisability affecting mobilityDyscalculiaDyslexiaHearing impairmentMental health difficultyModerate learning difficultyProfound complex disabilitiesSevere learning difficultySocial and emotional difficultiesSpeech, Language and Communication NeedsTemporary disability after illness (for example post-viral) or accidentVision impairmentOther disabilityOther learning difficultyOther medical condition (for example epilepsy, asthma, diabetes)Other physical disabilityOther specific learning difficulty (e.g. Dyspraxia)

Invalid Input

If other, please provide further details:

Invalid Input

Please provide any additional information that will help us to identify the support you will need:

Invalid Input

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What we do with the information we gather

We require this information to understand your needs and provide you with a better service, in particular for the following reasons:

• We will use the contact details provided to invite you to attend information and enrolment events in relation to your course and to request further information from you, where required, to support the admissions and enrolment process and to keep in touch with you before starting your course.
• We may use the information provided to monitor and support your progress as a student.
• We may use the information to improve our products and services.
• We may periodically send promotional emails about new products/services or other information which we think you may find interesting, using the mail address which you have provided.
• From time to time, we may also use your information to contact you for market research purposes. We may contact you by email, phone or mail.

Your personal information
By completing this form you are giving your consent to us processing your personal information in this way. We will not sell, distribute or lease your personal information to third parties unless we have your permission or are required by law. You have the right to request details of personal information which we hold about you.

For further information about we use and store your personal data, please read our Privacy Policy.

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Once you have hit the "Submit Form" button, please wait a moment while you are directed to our application confirmation page.