STUDENT ASSOCIATES SCHEME

Student Associate Application Form

This profile is intended to give some general background information. Should

you be accepted on to the Scheme the information will be used to assist in
planning your Student Associate programme and may be passed to your
placement school.

Personal details
First
Surname
Names
Former Names (e.g.
Maiden name)
Date of
Title (Please circle) Mr/Ms/Mrs/Miss/Dr Age
Birth
Address: Home / permanent residence Term Time

Home: Mobile: Term

Telephone
Time:

e-mail address/es:

When would you Please note that the period after the assessment period (ie June / July) is
be able to start not ideal, especially in secondary schools.
your placement?

Transport
available (please
indicate type)

Details of current Course of Study (the Scheme is available to part-time / full-time students
only)
Name of Institution
Type e.g. BA, BSc, Expected HESA USI
MA, PHD Completion number:

Main subject area

Subjects studied:

Previous Courses
at Higher Level:

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 How did you hear about the Student Associates Scheme?

Please indicate the type of placement you are applying for.

Tick the relevant boxes in either Primary or Secondary
Either
Men in Primary:
Do you have a preference for Infants or Junior
Infants Junior No preference
age group:
I would be interested in a placement at a school for pupils with Special Educational
Needs Yes / No

Or (Secondary)
Maths

Chemistry

Physics

Design and Technology

ICT
I would be interested in a placement at a school for pupils with Special Educational
Needs Yes / No

If there are no SAS vacancies in my chosen area I would be interested in learning more about any Yes No
non-bursary methods of gaining teaching experience (please tick relevant box)

Previous Experience
ACADEMIC
(post-16 subjects
studied)
Please state any post
16 qualifications, e.g.
INDUSTRY OR
WORK Please give
details of any
substantial previous
employment
Please list any experience of working with children or young people

Describe your ICT skills Have you any specific ICT skills you would like to
bring to our attention?
 Competent in several areas
 Quite competent
 Enough to get by on
 Little or no experience

Schools not to be used for placement

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Details of any schools with which you have existing connections or preferred
schools for placement

Please specify the area in which you prefer your placement (please note that
placements may be in a 10 mile radius).
Eg Cambridge / Norwich / S Norfolk / Yarmouth / N Norfolk / Kings Lynn / Ipswich. If outside
these areas, please specify a town.

Ethnic Origin: please underline which most closely describes your ethnic origin
from the following list.
White: Black or Black British: Asian or Asian British:
Mixed:
British Caribbean Indian Mixed White and Black
Caribbean
Irish African Pakistani Mixed White and Black
African
Scottish Other black background Bangladeshi Mixed White
and Asian
Other white background Chinese Other mixed
background
Other Asian background
Other ethnic background
Prefer not to provide information regarding ethnic origin

Do you have a disability?

If ‘yes’ please complete section on next page

Criminal Convictions:
The Scheme is exempt from the Rehabilitation of Offenders Act. This means that all applicants
are asked to disclose any relevant information. Do you have any criminal convictions,
including sentences, cautions, reprimands, final warnings, bind-over orders, cases
pending or considerations for possible prosecutions?
(Please
underline) YES NO
If ‘yes’ please give details on a separate page (we undertake not to discriminate unfairly
if information is revealed, as outlined within the CRB Code of Practice which is available on
request).
All successful applicants will be checked against ‘List 99’.

Do you have a current Criminal Records Bureau Disclosure? (Please

underline) YES NO
(If you are given a place on the Scheme we will need to process a new Disclosure
for you)

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Suitability Statement
In order to help with recruitment please submit a short statement giving reasons why you feel
you should be given a place on the Scheme. Please also take this opportunity to include any
further information that you feel may not have already been covered within this application
form.

I confirm that, to the best of my knowledge, the information on this form is true,
complete and accurate, and no information requested or other material information
has been omitted. I accept that if I do not fully comply with these requirements,
UEA shall have the right to cancel my application. I shall have no claim against the
institution.

Signature Date:

Please return completed application form to:

Student Associates Scheme
School of Education and Lifelong Learning
University of East Anglia
Norwich NR4 7TJ
or e-mail to: [email protected]

Do you have a disability?

If ‘yes’ please tick the appropriate box:

A No disability

B You have a social/communication impairment such as Asperger's syndrome/other

autistic spectrum disorder

C You are blind or have a serious visual impairment uncorrected by glasses

D You are deaf or have a serious hearing impairment

E You have a long standing illness or health condition such as cancer, HIV,
diabetes, chronic heart disease, or epilepsy

F You have a mental health condition, such as depression, schizophrenia or anxiety

disorder

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G You have a specific learning difficulty such as dyslexia, dyspraxia or AD(H)D

H You have physical impairment or mobility issues, such as difficulty using your
arms or using a wheelchair or crutches

I You have a disability, impairment or medical condition that is not listed above

J You have two or more impairments and/or disabling medical conditions

N Not Known

T Autistic disorder

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