Contact Details
Name
Address
Home postcode
Date of birth (dd/mm/yyyy)
Contact e-mail address
Contact telephone number
School or college name
SUPER details
Which week are you applying for? (please tick ONE)
29 th June – 3 rd July 2015

6 th July – 10 th July 2015

Don’t mind

I am interested in the possibility of a two-week placement: YES

NO

Please tell us why you would like to take part in the SUPER work experience programme and what you feel you would gain from being involved.

Personal details
Gender
Parent/carer’s occupation
Female
1)

Male

(please tick)
2)
Do any of your parents/carers have a Higher Education qualification (i.e. do they hold a degree?)
YES

NO

(please tick)
If YES, please provide details including university attended, course studied and year of graduation
(if known)
Do you intend to go to university?
YES

NO

Don’t know yet

(please tick)
What subjects do you think you may be interested in studying at university?
I (the student) consider myself to have a disability
YES

NO

(please tick)
If ticked YES please provide details of the nature of your disability including any additional support you feel you may need while participating in the SUPER programme.
I am a Looked After Young Person (currently living with people other than my parents or under the care of my Local Authority)
YES

NO

(please tick)
I am eligible for free school meals/the pupil premium
YES

NO

(please tick)
Please choose the category which you feel most closely resembles your ethnic origin
(  )
White
Gypsy or Traveller
Other Asian background
Mixed – White and Black Caribbean
Black or Black British – Caribbean
Black or Black British – African
Other Black background
Mixed – White and Black African
Mixed – White and Asian
Other Mixed background
Asian or Asian British – Indian
Asian or Asian British – Pakistani
Asian or Asian British – Bangladeshi
Chinese
Other – please give details
Arab
Other Ethnic background
Not known
Prefer not to say
(  )

If your application is successful, to enable you to take part we need to ask for some information for our programme records, as well as relevant permissions, as outlined below. Please note that we need this information to verify your eligibility to take part in the programme, and if you do not provide all of the details requested this may affect your participation.
The applicant.
 I confirm that I understand the nature and expectations of the programme I am applying for.
 I confirm that I will attend all scheduled activities in EITHER week 1 (29/06/15-03/07/15) or week 2 (06/07/15-
10/07/15) unless there are special circumstances that prevent me from doing so.
 I give permission for the data gathered about me as part of this application process to be passed onto the
University of Sheffield and stored securely.*
If I am successful in gaining a place on the programme:
 I give my consent to feature in any photos or videos that may be published as promotional or PR materials for the Project, e.g. in PowerPoint presentations, leaflets, brochures, on the University website or in local, national or world-wide press releases, without restriction.
 I consent to evaluate the activities I take part in, complete update requests and other studies (e.g. surveys or research activity) that may be requested during my time on the programme and subsequent interactions.
 I give my consent to share my personal details with relevant departments at the University of Sheffield in order that any future application to study at the University of Sheffield may be considered in light of my participation in a University of Sheffield outreach programme.

If I wish to opt out of any of the above, I understand that it is my responsibility to inform the SUPER coordinator of my decision.
I understand that this will not result in any repercussions for me.
Applicant signature
Please print name Date
The parent/carer
 I confirm that I understand the nature and expectations of the programme that my son/daughter/the young person in my care is applying for and give my permission for them to participate.
 I give permission for the data gathered about my son/daughter/the young person in my care as part of this application process to be passed onto the University of Sheffield and stored securely.*
If my son/daughter/the young person in my care is successful in gaining a place on the programme:
 I give consent for them to feature in any photos or videos that may be published as promotional or PR materials for the project, e.g. in PowerPoint presentations, leaflets, brochures, on the University website or in local, national or world-wide press releases, without restriction.
 I consent to allow my son/daughter/ the young person in my care to evaluate the activities they take part in, complete update requests and other studies (e.g. surveys or research activity) that may be requested during their time on the programme and subsequent interactions.
 I give consent to share my son’s/daughter’s/ the young person in my care’s personal details with relevant departments at the University of Sheffield in order that any future application to study at the University of Sheffield may be considered in light of their participation in a University of Sheffield outreach programme.
 If I wish for my son/daughter/the young person in my care to opt out of any of the above or to leave the programme I understand that it is my responsibility to inform the SUPER coordinator of this decision.
I understand that this will not result in any repercussions for me or my son/daughter/the young person in my care.
Parent/carer signature
Please print name Date
*Data Protection: The data provided in this form will be stored in accordance with the Data Protection Act 1988 and will be used to manage our outreach programmes. For monitoring purposes, anonymised data may be shared with HEFCE (the Higher Education Funding Council for England),
OFFA (the Office for Fair Access) and other teams within the University of Sheffield, to aid with monitoring and reporting of the effectiveness of our outreach programmes. Under the Data Protection Act, individuals have the right to see a copy of the data held about them. This can be obtained for a small fee by contacting us in writing.