Transcript of "Greenwich create it application form"
Create IT Summer School University of Greenwich, Avery Hill Campus 17th – 19th July 2012Student Information(Please complete in block capitals using blue or black ink)Name ________________________________________________________________________Home address ________________________________________________________________________ ________________________________________________________________________Tel no _____________________________________ Mobile ____________________________Email address ________________________________________________________________________Date of birth ________________________________________________________________________Gender Male FemaleYear Group 12 13 FEDo you consider yourself to have a disability? Yes NoThis information will help us to provide the most appropriate service for your needsIf 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 aperson’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 arelikely 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 *Severeallergies *Clinical depression *Heart / circulation / respiratory complaints *Learning disability *Severe agrophobia *Manic depressive illness *Respiratory conditionsWhich ethnic group do you belong to? White / British Mixed White & Black African White / Irish Mixed White & Asian White / Other Other mixed background Asian or Asian British / Indian Black or Black British / Caribbean Asian or Asian British / Pakistani Black or Black British / African Asian or Asian British / Bangladeshi Other Black background Other Asian background Chinese Mixed 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 theCreate 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 DataProtection Act (1998). Only organisations that require the information for the funding, delivery, evaluation andtracking of the Summer Schools Programme, the student’s school / college and the Higher Education StatisticsAuthority will be given access to the data. We will NOT use the data provided in this form for marketingpurposes.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 / CarerHave you and / or your partner had any experience of Higher Education (HE) in this country? Yes NoIf yes please give details of the qualification(s) you gained Mother / Carer Father / Carer Type of qualification: Type of qualification: Honours degree Honours degree Foundation degree Foundation degree HND / HNC HND / HNC Diploma of Higher Education Diploma of Higher Education Other, please state Other, please state Method of Learning: Method of Learning: Full time Full time Part 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 NoPlease read the information below:The Summer School is responsible for the welfare of your son/daughter while he/she is attending thecourse. As parents/carers, you are responsible for the welfare of your son/daughter up to the handoverpoint at the beginning of the course and again from the handover point at completion of the course. If yourson/daughter is allocated a place, the Summer School will contact you with details about these handoverpoints and travel arrangements.Data Protection 3
The information has been provided in this form is confidential and will be treated in accordance with theData 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 HigherEducation Statistics Authority will be given access to the data. We will NOT use the data provided in thisform 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.Declaration to be signed by Parent / CarerI have checked the information within this form and to the best of my knowledge it is correct and true.I have read the information above and understand that I will be responsible for my son / daughter up tothe handover point at the beginning of the course and again from the handover point at the completion ofthe course.I give permission for my child to attend the Summer School.I have checked the information within this form and to the best of my knowledge it is correct and true.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. Tohelp us determine this student’s eligibility for the scheme, please tick any one of the following factors whichapply: Looked – after child / Care Leaver Disability Lives in a deprived geographical area No parental / carer experience of Higher Education School / College has lower than average HE participation Other supporting factors (please state below)If the student has a disability, are there any special provisions which need to be made during the applicationprocess?_________________________________________________________________________________________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 theaddress below.Mrs Clair BushnellEvents CoordinatorUniversity of Greenwich 5