1. Create IT Summer School
University of Greenwich, Avery Hill Campus
17th – 19th 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 note
The 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 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)_____________________________________________
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2. 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 Protection
The 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
_________________________________
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3. 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 / 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 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 Protection
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4. The 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.
Declaration to be signed by Parent / Carer
I 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 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.
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 _____________________________________________________________
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5. 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) ___________________________________
Eligibility
The 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 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 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 Bushnell
Events Coordinator
University of Greenwich
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6. Pembroke 326
Chatham Maritime
Kent ME4 4TB
Tel: 0208 331 7598
Email: c.s.bushnell@greenwich.ac.uk
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