WIDENING PARTICIPATION

YEAR 12 ART HISTORY SUMMER UNIVERSITY 2016

Monday 4th - Thursday 7th July 2016

The Year 12 Art History Summer University is a Widening Participation initiative that targets young people from families whose parents or carers have not previously gone to University, or who currently receive Income Support or Tax Credits.

Places will be offered in priority to students that fit the criteria outlined below and in our publicity:

o  Students from a Widening Participation background, from families who have not been previously to Higher Education and who are interested in going to university

o  Students with a good academic record and/or a strong interest in Art and Humanities subjects

o  Students living in the Greater London area

Please print, complete, and send your application form—signed by your tutor and parent/guardian—as soon as possible.

Deadline to apply: Monday 22nd February – Monday 25th April 2016

Please send completed application forms by post or email to Helen Higgins/Meghan Goodeve,

This form can be filled electronically and returned to us via email, please type student’s, parent’s and tutor’s names where a signature is required.

Email:

Postal Address:

Helen Higgins/Meghan Goodeve
Oak Foundation Young People’s Programme Coordinator

Public Programmes
Courtauld Institute of Art
Somerset House, Strand

London, WC2R 0RN

For any further information, please contact us:

Tel.: 020 7848 1058.

For more information on this course:

http://courtauld.ac.uk/learn/schools-colleges-universities/young-people/summer-university


Please WRITE CLEARLY and complete the ENTIRE FORM.

Thank you for taking the time to complete the form.

First Name:
Surname: / Date of Birth:
Circle: Female or Male
Home Address:
Postcode:
Home Phone No: / Mobile Phone No:
Email Address: ______
How would you prefer we contact you: by email or by post (Please circle)

Information about your School or College

Name of School / College you are attending:
Address of School:
Postcode: / Borough:
Name of Secondary School (if different from above):
Address of Secondary School:
Postcode: / Borough:
Past study: please list your GCSE subjects and grades
Current study: Current AS/A level, IB or BTEC subjects

Contact Details of Parent or Guardian

Name of Parent or Guardian:
Contact phone number (in case of emergency): / Contact email:
Please describe any medical needs that we should be aware of (e.g. Allergies, Diets Conditions etc).
Do you have a disability that we should be aware of? Yes  No 
If yes, what is your disability:

Summer University 2016 is a Widening Participation project with specific funding to encourage students from families who have not previously been to Higher Education to apply to university.
Important: We won’t be able to consider your application unless this section is completed in full.

Do either of your parents have university
degree qualifications?
Mother/Guardian
Yes [ ] No [ ] Don’t know [ ] (Please tick)
Father/Guardian
Yes [ ] No [ ] Don’t know (Please tick)
What is your Mother/Guardian(s) job?
What is your Father/Guardian(s) job?
If your parents or guardian(s) are retired, please state their previous job above.
Do you receive the 16-19 Bursary Fund?
Yes [ ] No [ ] (Please tick)

Please tell us more about yourself:

Why would you like to attend the AHSU (100 - 300 words)?

Declaration Signed by a teacher or college tutor
I have checked the details on the application form. I confirm that they are correct and I support this application.
Name: Signature: (type name if filling in electronically)
Direct Telephone Number and/ or email:
Please add any relevant notes to support this student’s application:

Parents / Guardian Consent

(This section must be completed if the student applying for the course/ summer school is under 18 years of age.)

·  I am the parent / guardian of the above young person and I have read and understood the notes set out in the supporting information and I consent to him/her taking part in the above named course.
Signed: (type name if filling in electronically) Date:

Student Consent

I confirm that, to the best of my knowledge, the answers I have given on this application form are accurate. I can confirm that I am available to attend this course.
I would like to apply for a place.
Signed: (type name if filling in electronically) / Date:


Data Protection Act 1998

The Courtauld Institute of Art, London processes data in accordance with the Data Protection Act 1998. The personal information that you provide on these forms will be processed for purposes connected to the legitimate business of the University and may be transferred between all of the University departments. Some of the information that you provide on this form may be sent to the Funding councils, their agents and other statutory bodies for statistical and other purposes, including the National Student Survey.

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