Year 13 A Level Revision Bootcamp – Wednesday 1st – Friday 3rd June 2016
Part One: Application Form – to be completed by you and your parent/carer
1.
Your Personal Details
First Name:
Surname:
Address:
Postcode:
Home Telephone:
Your Mobile
Telephone:
Email Address:
D.O.B:
School:
Are you part of any Warwick or National Programme? (please tick to indicate):
 Pathways to Law
2.
 Realising Opportunities
Emergency Contact Details
1st Contact Name:
Relationship:
Contact Number:
2nd Contact Name:
Relationship:
Contact Number:
3. Medical Information / Dietary Requirements
Medical conditions or
special requirements:
 UniTracks
Current medication:
Any specific dietary
requirements:
4. Subject Preference
Please indicate by ticking the box below which is your 1st and 2nd subject preference (please note that
you will be following this one subject area for the full three days):
Subject
English
Literature
English
Literature
History
Exam Board
AQA
Topic
Love through the Ages
AQA
Gothic
AQA
History
Psychology
Chemistry
OCR/Edexcel
AQA A
AQA and OCR
Unit 3: Elizabethan
(H1S3B)
US Civil Rights
Unit 4 including QWC
AQA Units 4&5/OCR
F324 and F325
Mathematics
Biology
AQA and OCR
AQA
First Preference
Second Preference
C3/C4
Unit 4 and 5
5. Parent/Guardian/Carer Consent
Please indicate how your child will be travelling by ticking the appropriate box
Yes 
No 
By Train Yes 
No 
Yes 
No 
By Car
By Bus
I confirm I have read the enclosed information.
I agree to allow my son/daughter/child to attend the Year 13 A Level Revision Bootcamp at the
University of Warwick from 1st – 3rd June 2016 (9:30am – 5:00pm each day) and I accept all associated
terms and conditions.
Signature of parent/carer: _____________________________________
Name of parent/carer (please print):_____________________________
Date:_______________________________________________________
Data Protection
All personal data, as defined by the Data Protection Act 1998 (“the Act”) will be stored and used for selection purposes and to administer and
manage this applicant’s application. All personal data is processed in accordance with the Act and the University’s Data Protection policy:
www.warwick.ac.uk/legalservices/dataprotection.
Your data may also be shared with third parties such as the Higher Education Funding Council and the Higher Education Statistics Agency for
monitoring purposes, to help evaluate the effectiveness of this activity and to develop future policy. At no time will the information you
provide be used for marketing or sales purposes or be provided to any other organisation for this purpose. If you have any queries about the
use of your personal data please contact outreach@warwick.ac.uk.
Please now give this form to your Teacher to complete and return to us.
Year 13 A Level Revision Bootcamp – Wednesday 1st – Friday 3rd June 2016
Part Two: Application Form – to be completed by your teacher.
1.
Teacher Details
Full Name:
School Name:
Position at School:
School Address:
Postcode:
Contact Telephone
Number:
Email Address:
2. Teacher Declaration
I confirm I have read the enclosed information.
I nominate this student to attend the A Level Revision Bootcamp and can confirm that they have
applied through UCAS this academic year and that they meet the following criteria:
(please note that to be eligible, students must meet at least one of the criteria below)
 Come from a home where neither parent/carer has attended university in the UK;
 Have been in receipt of, or eligible for free schools meal/pupil premium over the last 6 years (Ever
Six);
 Be in current receipt of a means tested bursary;
 Lives in an eligible postcode area (neighbourhood with low progression rate to higher education or
with high levels of deprivation)*;
 Lives in or having lived in local authority care.
* postcode eligibilty can be checked by the event manager.
Whilst places at the A Level Revision Bootcamp 2016 are free for participants, please note that once a
place has been offered and accepted by the student, the nominating school will be charged a fee of £50
if the student does not attend the whole or part of the event, without a compelling reason.
Signature of Teacher: _________________________________
Date:_______________________________________________
Please return this form via email to outreach@warwick.ac.uk or post to Outreach Team,
SROAS, University House, University of Warwick, CV4 8UW
Deadline for receiving applications: Friday 15th April