I am a member of: (please tick)
12th - 16th July 2016
□ UniTracks
□ Realising Opportunities
□ Pathways to Law
□ None of the above
Places on the Experience Warwick 2016 Year 12
Summer School are reserved for students from nonselective state schools in the UK who are amongst
the most academically able in their schools.
Teachers should return this form by
Thursday 17th March 2016 to:
Places on the Experience Warwick Summer Schools
are offered on a competitive basis and applicants
should fulfil the key eligibility criteria and be able to
explain why they would benefit from a place on the
Summer School (Section Two).
Experience Warwick Year 12 Summer School
Widening Participation Team
Student Recruitment, Outreach and
Admissions Service
University of Warwick
University House
Coventry
CV4 8UW
How to complete this form
Section One: Personal Information
Before you complete this form, please discuss the
Summer School with your teacher to make sure that
it is something you would like to do, and that you
can apply for a place.
(to be completed by the applicant)
This form is split into four sections:
Home address:
Applicants must meet at least three of the eligibility
criteria (Section 4).
Section 1:
Your personal information
This is to be completed by the APPLICANT.
Section 2:
Information about you and your interests
This is to be completed by the APPLICANT.
Section 3:
Parental Consent
This is to be completed by your PARENT/CARER.
Section 4:
Teacher Declaration
This is to be completed by the TEACHER who
gave you this application form.
Surname:
First name(s):
Postcode:
Home number:
Mobile number:
Email address:
Gender (please tick)
□ Male □ Female
Date of Birth:
School/College you currently attend:
Postcode of School/College:
Year group:
Section Two: Background Information (to be completed by the applicant)
Which Ethnic Group do you belong to?
Predicted A Level grades or equivalent:
This information will not be used for selection purposes.
□ White
□ Black or Black British – Caribbean
□ Black or Black British – African
□ Other Black Background
□ Asian or Asian British – Indian
□ Asian or Asian British – Pakistani
□ Asian or Asian British – Bangladeshi
□ Chinese
□ Other Asian Background
□ Mixed – White and Black Caribbean
□ Mixed – White and Black African
□ Mixed – White and Asian
□ Other Mixed Background
□ Other Ethnic Background
□ Not Known
Subject
Grade
Please rate the following statements, marking
1 where you strongly disagree and 5 where you
strongly agree: (The answers to these questions will
have no impact on the success of your application and
will only be used for evaluative purposes.) Please circle
appropriate rating.
1) I am just as likely to go to university as anyone else.
STRONGLY
DISAGREE
1
2
3
4
5
STRONGLY
AGREE
2) I have a clear idea about the type of university
I might like to attend in the future.
STRONGLY
DISAGREE
We need the following information in order to cater for
any individual requirements you may have.
Do you consider yourself as having a learning
difficulty or disability?
1
2
3
4
5
STRONGLY
AGREE
3) I am planning to apply to university in the future.
STRONGLY
DISAGREE
1
2
3
4
5
STRONGLY
AGREE
What is your current impression of university?
□ Yes □ No
Do you have any specific needs we can assist with?
□ Yes □ No
If yes to either, please give details
At this stage do you know what you might like to
study at university? If yes, please give brief details.
Are you/have you been in care?
□ Yes □ No
Achieved GCSE grades:
Subject
Grade
Why should we select you for a Summer School
this year? This is your chance to tell us why you
should be selected to attend our Summer School. We
want to know all about you – your interests, your
hobbies and your ambitions for the future and how you
think attending our Summer School will benefit you.
Please use the insert enclosed to explain why you
would like to be part of our Summer School.
Once completed give this form to your parent/carer
to complete Section Three.
Section Three: Family Information (to be completed by parent/carer)
Has your son/daughter/this applicant been in
receipt of free school meals over the last six years?
□ Yes □ No
Second Parent/Carer (if applicable)
First name:
Surname:
Relationship to student:
First Parent/Carer
What is your current occupation?
First name:
Surname:
Relationship to student:
What is your current occupation?
Are you currently studying/or have you completed
a course in Higher Education?
□ Yes □ No
If yes, please state name of institution and year began/
completed.
Highest type of qualification gained. Please tick:
□ Higher Degree (e.g. PhD, PGCE)
□ First Degree (e.g. BA, BSc)
□ Higher National Diploma (HND)
□ Higher National Certificate (HNC)
□ NVQ Level 4 or 5
□ A Levels/AVCE/BTEC/IB
□ GNVQ
□ NVQ Level 3
□ GCSE/O Level/CSE
Other (please specify)
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 warwicksummerschools@warwick.ac.uk.
Please ask the applicant to return this form to their
teacher so that they can complete Section Four and
return it to us.
Are you currently studying/or have you completed
a course in Higher Education?
□ Yes □ No
If yes, please state name of institution and year began/
completed.
Highest type of qualification gained. Please tick:
□ Higher Degree (e.g. PhD, PGCE)
□ First Degree (e.g. BA, BSc)
□ Higher National Diploma (HND)
□ Higher National Certificate (HNC)
□ NVQ Level 4 or 5
□ A Levels/AVCE/BTEC/IB
□ GNVQ
□ NVQ Level 3
□ GCSE/O Level/CSE
Other (please specify)
Declaration to be signed by parent/carer
I have completed this form to the best of my knowledge.
I have read the information above and understand that I will be
responsible for my son/daughter/this applicant up to the handover
point at the beginning of Summer School and again from the
handover point at the completion of Summer School.
I confirm that my son/daughter/this applicant has no previous
commitments during the 12th - 16th July 2016, including holidays
away and is free to attend the Summer School.
Photo consent
I give permission for my son/daughter/this applicant to be
photographed and/or filmed during the aforementioned
Summer School and for the University of Warwick to
use these images for the future promotion of Outreach
programmes taking place within the institution.
□ Yes □ No
I give permission for my son/daughter/this applicant to attend the
Summer School and for the information on this application form
to be stored by the University of Warwick.
Name of Parent/Carer:
Email of Parent/Carer:
Contact No. of Parent/Carer:
Signature of Parent/Carer:
Date:
Section Four: Teacher Declaration (to be completed by teacher)
Name of contact teacher/tutor:
Name of school:
School address:
Postcode:
Phone number of contact teacher/tutor:
Fax number:
Email address:
Please confirm the student’s eligibility below.
To be eligible applicants must meet at least three of the criteria below:
□ Have achieved 8 A*-C grades at GCSE (5 of which are grade B or above)
□ Come from a home where neither parent attended university in the UK or abroad
□ Has the student been in receipt of/or eligible for free school meals or Pupil Premium over the last six years (Ever 6)?
□ Be in receipt of discretionary means tested payments, 16-19 bursary or eligible for pupil premium
□ Live in an eligible postcode (neighbourhood with low progression rate to higher education or with
high level of financial, social and economic deprivation)*
□ Living or having lived in local authority care
□ Be a member of one of the University of Warwick access programmes (Unitracks, Pathways, Realising Opportunities)
* The Summer School manager will check the postcode using our postcode checker.
Number of predicted A Level grades: (Please write numbers in boxes)
A*
□
A
□
B
□
C
□
D
□
E
□
This student has other circumstances which need to be considered. (This may include social, economical, educational)
If yes, please state:
This form has been completed to the best of my knowledge and I confirm that all details are correct and am in support
of this application.
Signature:
Date:
PLEASE ENSURE THAT ALL SECTIONS OF THIS FORM ARE COMPLETED AND RETURNED TO
THE ADDRESS STATED ON THE FRONT OF THE FORM BY Thursday 17th March 2016.