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Nationality*

Which programme do you wish to apply for? Please include full title of programme including qualification level (Degree, Certificate in Higher Education (CertHE))*

Please list all subjects taken, whatever the result, in chronological order. Include the qualification, subject, completion date, institution name, and result.*

Please provide a personal statement that sets out your reasons for undertaking the course. *

Name of Referee*

Student Name

Self-declaration form

Do you have a disability, long-term health condition, or learning difference? Please select the options below that apply:

 
08 Two or more impairments and/or medical conditions51 A specific learning difficulty such as dyslexia, dyspraxia or ADHD53 A social/communication impairment such as Asperger’s syndrome/other autistic spectrum disorder54 A long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, or epilepsy55 A mental health condition, such as depression, schizophrenia or anxiety disorder56 A physical impairment or mobility issues, such as difficulty using arms or using a wheelchair or crutches57 Deaf or a serious hearing impairment58 Blind or a serious visual impairment uncorrected by glasses96 A disability, impairment or medical condition that is not listed above

Please select the options below that best describes your ethnicity:

 
10 White15 Gypsy Traveller21 Black or Black British – Caribbean22 Black or Black British – African29 Other Black background31 Asian or Asian British – Indian32 Asian or Asian British – Pakistani33 Asian or Asian British - Bangladeshi34 Chinese39 Other Asian background42 Mixed – White & Black African43 Mixed – White & Asian49 Other Mixed background50 Arab80 Other Ethnic background90 Ethnicity not known98 Prefer not to say

If you have a relevant conviction that is not spent please tick the box, otherwise leave it blank.