1 Year Young Persons University 2015 Residential Summer School Programme Application Form There are three sections to this application form: Section 1: To be completed by the applicant Please complete all the details required on the application form. Once you have completed the form and signed the declaration please give it to your parent/carer to fill in section 2. Section 2: To be completed by the applicant s parent / carer Please get your parent / carer to complete and sign this form. Please note that without a signature from a parent or carer, we will be unable to process your application form. Then you need to give the form to your teacher. Section 3: To be completed by the applicant s teacher / tutor Please get your teacher to complete this section as the University will need to have confirmation that you will be allowed to attend the programme during term time. They will then send your application form to the university. Please ensure you have fill in the form in BLOCK CAPITALS. Failure to complete all relevant parts of the form will mean your application cannot be processed so please be thorough. The deadline for applications is Friday 8 May Once you have checked the form is complete please send to the Widening Participation team at the University of Surrey. Widening Participation and Outreach University of Surrey Senate House Guildford, GU2 7XH
2 Young Persons University and Subject Choice Please tick the Young Persons University you would like to attend. Please select one Young Persons University from the table below, by placing a tick in the box. Then select which strand of that YPU you would like to attend. If you are interested in more than one strand then please select in order of preference, and indicate this in the boxes e.g. 1,2,3. Engineering and Physical Sciences Young Persons University 29 June - 2 July The Business World 29 June - 2 July Physical Sciences (Maths, Physics and Computing) Engineering Business Subjects Law Hospitality and Tourism Languages 29 June - 2 July French German Spanish One Health 14 July - 17 July Health Sciences 14 July - 17 July Sports and Nutrition Science Biomedical Science Veterinary Science Nursing and Midwifery Operating Department Practice Paramedic Practice
3 Section 1: To be completed by the Student A Your Contact Details Name Home Address Postcode Home Telephone Mobile Number Date of BIrth School Gender Female Male B About You Ethnicity - Please circle the category which best describes yourself. White: English / Welsh / Scottish / rthern Irish / British Irish Gypsy or Irish Traveller Any other White background Mixed / Multiple ethnic groups: White and Black Caribbean White and Black African White and Asian Any other Mixed / Multiple ethnic background Asian / Asian British: Indian Pakistani Bangladeshi Chinese Any other Asian background Black / African / Caribbean / Black British: African Caribbean Any other Black / African / Caribbean background This information will be used for evaluation purposes and not for place allocation. Do you have a disability or long term health problem which affects your daily life? (includes mobility difficulties, hearing impairments, visual impairments, specific learning difficulties, including dyslexia, medical conditions and mental health problems) If you answered YES, please specify your disability: Other ethnic group Arab Any other ethnic group, please describe The University of Surrey will contact you to discuss any additional support you might need. Have you ever been looked after by a local authority? Are you a young carer? Age on 1 June 2015 (you care for a friend or family member who due to illness, disability, a mental health problem or an addiction cannot cope without your support)
4 Section 1: To be completed by the Student C Your Education Secondary School Name of Secondary school GCSE English grade/s: GCSE Maths grade/s: GCSE Science grade/s: Current Sixth Form/College Subjects you are currently studying please include the type of qualification, subject, and predicted Name of Sixth Form/College grades (eg. AS Level, English, grade B). Type of qualification and subject: Year Are you planning to go to University? Unsure If, please indicate the type of course and qualifications you are interested in. Predicted grades: Have you attended a Summer School before? If, please give details of when you attended and where it was held. D Hobbies, interests or work experience relevant to this Young Persons University subject choice Your Application Personal Statement Please include information about: Why you wish to attend Your ambitions for the future Extra space on next page
5 Section 1: To be completed by the Student D Your Application Personal Statement Have you attended or been involved in any of the following? E Careers Fairs Subject Workshops Subject Taster Days UCAS Fair/Open Day Please tick to confirm you are happy for us to contact you. Your Declaration We may wish to contact you in the future to send useful information, updates about the University of Surrey and for research purposes I have checked the information within this form and to the best of my knowledge it is correct and true. I understand that I should contact the University of Surrey directly with a problem or if I am no longer able to attend. Signature Print Name Date Thank you for completing section 1 Please hand the application form to your Parent/ Guardian to complete section 2.
6 Section 2: To be completed by the Parent / Carer / Guardian A Parent / Guardian / Carer details Please complete in as much detail as possible and in BLOCK CAPITALS. We may use these details to verify any information or in the event of an emergency. If you need to update your details closer to the event, please contact us. Name of Parent / Guardian / Carer Relationship to applicant Occupation Retired Unemployed Day time telephone Mobile telephone address Have you completed a university degree? If, please provide details below Degree Awarded Institution Year of Graduation Please tick this box if you are a single parent family. If not, please fill in the second parent information box Name of Parent / Guardian / Carer Relationship to applicant Occupation Retired Unemployed Day time telephone Mobile telephone address Have you completed a university degree? If, please provide details below: Degree Awarded Institution Year of Graduation D About your child Does your child have any of the following? Special Educational Needs or Disabilities (Including specific learning difficulties such as dyslexia, dyspraxia and dyscalculia) Medical Conditions Allergies Special Requirements (Dietary, Religious i.e. Ramadan) If you have ticked to any of the above please provide details below, including medication and/or special provision required: We may contact you to discuss your child s needs. This information will be used to provide the most appropriate support for your child s needs. We are particularly keen to encourage young people who may have special educational needs and/or disabilities to consider higher education as an option for them.
7 Section 2: To be completed by the Parent / Carer / Guardian E Marketing and Data Protection During the Young Persons University, photographs and/or video/digital footage of your child participating in activities may be taken. We would hope, in this way, to give your child a reminder of their experience. We may also wish to use this material, with no names attached, to encourage other young people to take part in a Young Persons University (for example, by using it in future printed and web-based Young Persons University publicity or University Prospectuses). Please tick to confirm you are happy for your child s image to be used in this way. Data Protection: Student data collected as part of the evaluation will be stored on a student database in accordance with the Data Protection Act. We will also be using the information in an anonymous way to report on the activities to both internal and external stakeholders. Data may also be shared with both internal and external stakeholders to help evaluation the effectiveness of our activities as part of the government policy to widen participation in higher education and to develop future policy. F Please tick to confirm you are happy for data to be used in this way. Responsibility for your Child I understand that I will be responsible for my child up to the handover point at the beginning of Young Persons University and again from the handover point at the completion of the programme. I understand the University of Surrey has a duty of care to my child while he/she is attending Young Persons University and as such grant my permission to allow the University of Surrey to act appropriately in the event of an emergency, including the administering of first aid treatment and referral to hospital if necessary, acknowledging that the University of Surrey will always liaise with me directly where possible. Parent/ Guardian/ Carer Signature: Please return this form to your child for section 3 to be completed by your child s teacher. Print Name: Thank you for completing section 2. Date:
8 Section 3: To be completed by the Teacher Please ensure this section is completed by a teacher or tutor who knows the student. This member of staff will act as a referee and may be contacted to verify any information. A Contact Details Name of Teacher Job Title/Post Full School/College name Contact phone number Teacher address B Predicted Grades Are the predicted grades provided in section 1 correct? If no, please include predicted grades below: Type of qualification and subject: Predicted grades: C Teachers Statement Please comment on the following: Overall academic ability and general performance at school/college and predicted grades if possible Suitability and maturity to attend an intense academic early-university level course Why this student may benefit from this type of activity Any information you believe will have a bearing on the student s application or which you think would be helpful for us to be aware of (such as family circumstances, aspirations/awareness of HE and potential of student). I have checked the details on this application form and I confirm that, to the best of my knowledge, E Teachers Declaration they are correct and I support this application. Teachers Signature: Print Name: Date: Thank you for taking the time to fill in this form and supporting the application process Application Deadline: Friday 8 May