1. YEAR 12 ENGLISH SUMMER SCHOOL APPLICATION FORMPLEASE WRITE CLEARLY AND USE BLACK INK, BLOCK CAPITALS AND TICK BOXES AS APPROPRIATE.THE DEADLINE FOR APPLICATIONS IS FRIDAY 25th MAY 2012.PERSONAL DETAILS1. First name 2. Surname/Family name 3. Gender 4. Date of Birth Male Female Day Month Year5. Home Address 6. Telephone Number 7. Email Address Postcode8. Which ethnic group do you belong to? (We require this information for equal opportunities purposes only.)Asian or Asian British Black or Black British White Bangladeshi African White British Chinese Caribbean White Irish Indian Black – Other (please specify below) White – Other (please specify below) Pakistani Mixed – Other (please specify below)Mixed Other White and Asian Other ethnic group (please specify below) White and Black African White and Black Caribbean Mixed – Other (please specify below)9. Do you have a disability 10. If yes, what is your disability? Yes NoWe encourage applications from students with disabilities and require this information for equal opportunities purposes only. The Disability DiscriminationAct 1995 defines disability as ‘a physical, sensory or mental impairment which has a substantial and long-term adverse effect on a person’s ability to carryout normal day-to-day activities’. This definition includes a wide range of sensory impairments, mental illnesses and learning difficulties, as wellas medical conditions that are likely to last 12 months or longer, or are likely to recur.ABOUT YOU11. Have you achieved five or more GCSEs at grades A*-C? Yes No12. What is your predicted grade for A-level English?13. Have you been to a summer school before? Yes No14. If yes, at which university and in what year?
2. 15. Why do you want to attend this summer school? (maximum 100 words)16. Describe a work of literature that has inspired you and why. (maximum 100 words)Please ask your parent/guardian to complete and sign the parental/guardian consent form. Please give your completed application and parentalconsent form to your teacher. Your teacher will then complete his/her section and send the form to UCL on your behalf.
3. PARENT/GUARDIAN CONSENT18. Name of student 19. Name of parent/guardian20. Relationship to applicant Mother Father Guardian Carer21. Your occupation 22. Your partner’s occupation (if applicable)23. Have you or your partner been to university? Yes No24. If yes, which university and what did you study?You PartnerDATA PROTECTIONThe UK Data Protection Act (1998) requires us to obtain your explicit consent to process and retain your child’s data.The summer school is designed to target students from communities who are under-represented in higher education. Information about parent/guardian occupation and educational background may be used for the purposes of selection and for monitoring the backgrounds from whichapplicants apply.At no time will your or your child’s personal information be passed to other organisations.Declaration to be signed by a parent/guardian/carer• I have completed the form with the information to the best of my knowledge.• I consent to the use of personal data as described above.• I am the applicant’s legal guardian.• I give permission for my son/daughter to attend the summer school.Signature DatePlease ask your son/daughter to hand their application and the parental consent form to their teacher.
4. TEACHER’S REFERENCE25. Name of student 26. Name of school27. School Address 28. Local Authority Postcode Telephone Number Email Address29. EligibilityWhich of the following factors apply? Both parents/guardians have no experience of Higher Education The student has a disability The student is entitled to free school meals/EMA replacement The student is living under Local Authority care30. If necessary, please give details of any other factors which may affect the student’s likelihood of progressing to Higher Education.Declaration to be signed by a teacherI have checked the details on the application form. I confirm they are correct, and I support this application.Name of teacher Job titleSignature DateWe may have to limit places to students from the same school. If more than one student is applying from your school, please givethe students a ranking, with 1 indicating the student who would benefit most from the summer school.Ranking (if applicable)Please return all application forms for students from your school to:UCL English Department University College London Gower Street London WC1E 6BTThe deadline for applications is Friday 25th May 2012.