Greenwich create it application form

Create IT Summer School University of Greenwich, Avery Hill Campus

17 th – 19 th July 2012

Student Information(Please complete in block capitals using blue or black ink)

Name ________________________________________________________________________

Home address ________________________________________________________________________

________________________________________________________________________

Tel no _____________________________________ Mobile ____________________________

Email address ________________________________________________________________________

Date of birth ________________________________________________________________________

Gender Male Female

Year Group 12 13 FE

Do you consider yourself to have a disability? Yes No

This information will help us to provide the most appropriate service for your needs

If yes, what is the nature of your disability?__________________________________________________________

Definition of disability – an explanatory noteThe Disability Discrimination Act defines disability as “physical or mental impairment which has substantial and long term adverse effect on a person’s ability to carry out normal day to day activities.”

The definition includes a wide range of sensory impairments, mental illnesses and learning disabilities, as well as medical conditions that are likely to last 12 months or longer or are likely to reoccur.

The following are examples of impairments or long-term conditions that could be considered disabilities under this definition:*Arthritis *Sensory impairment *Long term back/neck problems *Dyslexia *Severe facial disfigurement *Diabetes *Multiple sclerosis *Severe allergies *Clinical depression *Heart / circulation / respiratory complaints *Learning disability *Severe agrophobia *Manic depressive illness * Respiratory conditions

Which ethnic group do you belong to?

White / British Mixed White & Black AfricanWhite / Irish Mixed White & AsianWhite / Other Other mixed backgroundAsian or Asian British / Indian Black or Black British / CaribbeanAsian or Asian British / Pakistani Black or Black British / AfricanAsian or Asian British / Bangladeshi Other Black backgroundOther Asian background ChineseMixed White and Black Caribbean Other ethnic background. Please state:

Please tell us:a) Which subjects do you currently enjoy studying?

1) __________________________________________ 2)________________________________________

3) __________________________________________ 4)_____________________________________________

1

b) Which subjects would you like to study in the future?

1) __________________________________________ 2)________________________________________

3) __________________________________________ 4)_____________________________________________

Using the questions below, please provide information on why you consider yourself a suitable candidate for the Create IT programme.

1) Why do you wish to attend?

_________________________________________________________________________________________

2) What are your ambitions for the future?

_________________________________________________________________________________________

3) Do you have any hobbies or have you completed any work experience relevant to the Create IT Summer School?

_________________________________________________________________________________________

4) Any other additional information?

_________________________________________________________________________________________

Data ProtectionThe information has been provided in this form is confidential and will be treated in accordance with the Data Protection Act (1998). Only organisations that require the information for the funding, delivery, evaluation and tracking of the Summer Schools Programme, the student’s school / college and the Higher Education Statistics Authority will be given access to the data. We will NOT use the data provided in this form for marketing purposes.

I have checked the information within this form and to the best of my knowledge it is correct and true.

Signature _______________________________________________________________________________

Print Name _________________________________________ Date _________________________________

2

Parent / Carer Information and Consent (To be completed by your Parent / Carer, in block capitals)

Name of Parent / Carer _____________________________________________________

Daytime contact telephone number _____________________________________________________

Alternative number (eg work / mobile) if possible _________________________________________________

Relationship to the applicant _____________________________________________________

Mother / Carer’s occupation _____________________________________________________

Father / Carer’s occupation _____________________________________________________

Main wage earner (or person responsible for accommodation) Mother/ Carer Father / Carer

Have you and / or your partner had any experience of Higher Education (HE) in this country?

Yes No

If yes please give details of the qualification(s) you gained

Mother / Carer Father / CarerType of qualification: Type of qualification:

Honours degree Honours degreeFoundation degree Foundation degreeHND / HNC HND / HNCDiploma of Higher Education Diploma of Higher EducationOther, please state Other, please state

Method of Learning: Method of Learning:Full time Full timePart time Part time

Name of institution: Name of institution:

Were you 21 or over at the start of the course? Were you 21 or over at the start of the course?

Yes No Yes No

Please read the information below:The Summer School is responsible for the welfare of your son/daughter while he/she is attending the course. As parents/carers, you are responsible for the welfare of your son/daughter up to the handover point at the beginning of the course and again from the handover point at completion of the course. If your son/daughter is allocated a place, the Summer School will contact you with details about these handover points and travel arrangements.

Data ProtectionThe information has been provided in this form is confidential and will be treated in accordance with the Data Protection Act (1998). Only organisations that require the information for the funding, delivery, evaluation and tracking of the Summer Schools Programme, the student’s school / college and the Higher Education Statistics Authority will be given access to the data. We will NOT use the data provided in this form for marketing purposes.

Please note: Due to both the Data Protection Act (1998) and child protection policies, only the parent / carer who has signed the form can be given access to the data provided.

3

Declaration to be signed by Parent / Carer


I have read the information above and understand that I will be responsible for my son / daughter up to the handover point at the beginning of the course and again from the handover point at the completion of the course.

I give permission for my child to attend the Summer School.


Signature of Parent / Carer _____________________________________________________________

Print Name _____________________________________________________________

Date _____________________________________________________________

4

School / College Information(To be completed in Block Capitals)

Name of Teacher / Mentor ___________________________________________________________

Full name of School / College ___________________________________________________________

School / College Address ___________________________________________________________

___________________________________________________________

Telephone number ___________________________________________________________

Email address ___________________________________________________________

Name and contact number of Child Protection Officer (if applicable) ___________________________________

EligibilityThe student must have the potential to proceed to Higher Education and must be in either year 12, 13 or FE. To help us determine this student’s eligibility for the scheme, please tick any one of the following factors which apply:

Looked – after child / Care LeaverDisabilityLives in a deprived geographical areaNo parental / carer experience of Higher EducationSchool / College has lower than average HE participationOther supporting factors (please state below)

If the student has a disability, are there any special provisions which need to be made during the application process?_________________________________________________________________________________________

I have checked the details in the application form. I confirm they are correct and I support this application.

Signature of Teacher / Mentor ___________________________________________________________

Print name ___________________________________________________________

Date ___________________________________________________________

Once you have checked that all the sections have been completed, please send this application form to the address below.

Mrs Clair BushnellEvents CoordinatorUniversity of GreenwichPembroke 326Chatham MaritimeKent ME4 4TB

Tel: 0208 331 7598Email: [email protected]

5