College – Supported Internship/CE

Student Details:

First Name *

Last Name *

Date of birth *

Preferred To Be Known As

Pronoun

Home Phone Number *

Mobile Number *

Student Email *

Address *

I can confirm that I/The Student can manage a 5 day timetable?
YesNo

If you are aged between 16 and 18 years of age, have you achieved the required grades in GCSE English and Maths?
YesNo

Please select your preferred campus *
LeedsManchesterStokeBirmingham

Please select your preferred programme? *
Supported InternshipCreative Enterprise

Proposed Start Date
—Please choose an option—Year 25/26Year 26/27

Local Authority SEND case worker

Your Local Authority

Social Worker (If you have one)

Known SEND need. Tick all that apply *
ADHDAnxietyASC/AutismCerebral PalsyDyslexiaDyspraxiaEpilepsyHearing impairmentMental health difficultiesPhysical disabilityVisual impairmentOther

Your creative interests, career aspirations and other things about you that you would want us to know *

Does the young person have an EHCP/ Statement (Wales) *
YesNo

Does the young person have any Safeguarding incidents/issues and/or a Risk Assessment *
YesNo

How did you hear about Pinc College? *
LinkedInFacebookInstagramX.comEmailCareers AdvisorLocal AuthoritySocial WorkerHealth ProfessionalParent or Carer GroupOther

Parents / Carers / Corporate Parent:

First Name *

Last Name *

Mobile Number *

Email *

Relationship to Student

Address (if different) *

Emergency contact details if different from above:

Name

Relationship to Student

Telephone

Emergency contact details if different from above:

Current School or College

Address

Date From / To

Most Recent Attendance (Average)
Below 20%20% - 50%50% - 80%Above 80%

Wellbeing
GoodSome ConcernsReq. Intervention

Overall Attainment
ExcellingSome ConcernsNo Progress

Qualifications:

Subject 1

Grade or Expected Grade

Date (Year) Completed/Expected

Subject 2

Grade or Expected Grade

Date (Year) Completed/Expected

Subject 3

Grade or Expected Grade

Date (Year) Completed/Expected

Subject 4

Grade or Expected Grade

Date (Year) Completed/Expected

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