Pre-University Summer School in Medicine Application Form
17 – 30 July 2016
Please complete this form and email it to: iss@exeter.ac.uk with the following:
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confirmation of your most recent grades at high school
a reference letter from your school
evidence of your English language proficiency
Section 1: Personal Details
First name:
Last name(s):
Date of birth (DD/MM/YY):
Gender:
Nationality (as it appears on your passport):
Address:
Email address:
Telephone number (including international code):
Section 2: Parent/Guardian Details
First name:
Title:
Last name(s):
Relationship to applicant:
Address:
Email address:
Telephone number (including international code):
Section 3: Education Details
Please give full details of your current or most recent school/college.
Name of School/College:
School Address:
Dates of study (dd/mm/yyyy):
From: __/__/____
To:
__/__/____
Subjects and Grades - please list all of the courses you are currently studying and your most recent
grades:
Have you ever studied in the UK? Yes
No
If ‘Yes’ please provide details of the institution name and dates of study:
Section 4: English Proficiency Details
Is your first language English or is the language of instruction at school English?
Yes
No
(please tick relevant box)
If you answered ‘No’, please tell us how you meet our English proficiency requirements
(refer to link when live)
Name of your English qualification and score:
(Include the overall and component scores if relevant)
Section 5: Reference
Please provide the following details about your referee:
Name:
School Address:
Email:
Job Title:
Date of test:
Section 6: Personal Statement
Please tell us why you are interested in attending the pre-university summer school in Medicine and
what benefits do you hope to gain by attending?
Section 6: Welfare
If you answer ‘Yes’ to any of the following questions, please provide full details in a separate
document:
Do you have any conditions, medical or otherwise that may impact your time on the programme?
Yes
No
Do you consider yourself to have a disability?
Yes
No
Have you been convicted of a relevant criminal offence? (i.e. excluding driving convictions)
Yes
No
Section 7: Declaration
The University of Exeter requires the information you provide on this form for educational purposes.
Your personal data will be processed in accordance with the University's registration and current data
protection legislation in the UK.
I confirm that the information I have given is complete and correct:
Yes
No
I have read and understood and agree to abide by the Terms and Conditions (add link):
Yes
No
Where did you hear about the Summer School?
Signed: ____________________________________ Date: __/__/____