SUPER – Student Application Form
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)
4th July – 8th July 2016 
11th July – 15th July 2016

I am interested in the possibility of a two-week placement:
Don’t mind
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
Female 
Gender
Parent/carer’s
Male 
1)
(please tick)
2)
occupation
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)
NO

(please tick)
I am a Young Carer
YES 
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
Other Asian background
Gypsy or Traveller
Mixed – White and Black Caribbean
Black or Black British – Caribbean
Mixed – White and Black African
Black or Black British – African
Mixed – White and Asian
Other Black background
Other Mixed background
Asian or Asian British – Indian
Arab
Asian or Asian British – Pakistani
Other Ethnic background
Asian or Asian British –
Not known
Bangladeshi
Chinese
Prefer not to say
Other – please give details
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 (04/07/1608/07/16) or week 2 (11/07/16-15/07/16) 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 collected here will be processed by the University of Sheffield in
accordance with the Data Protection Act 1998 and held for an extended period of time. For
research, monitoring and evaluation purposes only, your data may also be shared with
appropriate third party organisations such as the Higher Education Funding Council for
England, Higher Education Statistics Agency and our partners including Higher Education
Access Tracker Service subscribers. We will not release data to anyone who is unauthorised.
Under the Data Protection Act 1998 you have the right to a copy of the data held about you
by us. If you would like a copy of the data you have supplied to us, please contact
heat@sheffield.ac.uk. By submitting your application, you are consenting to the use of your
data as outlined above.
If you do not wish to be contacted by the University of Sheffield about future activities,
please tick here ☐
As part of this application, we have collected data regarding ethnicity, disability and health
and social care for monitoring equality of opportunity under the Equality Act 2010. Please
tick here if you are happy for this information to also be used for evaluation and
monitoring purposes ☐