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Registration Form:First name: Last name:

Date of birth: Age:

Gender (please circle) : M / F

Home address:

Postcode: Borough:

Phone: Mobile:

Email:

Emergency contact:

Name: Phone:

Relationship:

Are you currently? (please circle)

Studying Working

Both

Name of school or college:

Studying (please circle):

GCSE A/ AS Levels

NVQ BTEC

> STEP 1: • Fillintheenrolmentform

andenterthenamesoftheChallengeWeeksandcodesinorderofpreference.

• MakesurethedatesoftheChallengeWeeks/coursesdon’tclash.

• Ifyouareunder18,askaparent/carertosigntheirconsent.

> STEP 2:

• Tearorcutoff(orphotocopy)theformandsenditto:

Summer Uni 4U 125 Freston Road London W10 6TH

> STEP 3:• Allcourseshavelimited

placesavailable.• SummerUni4Uwillbe

intouchbyletterofferingyouaplace.

• Contactustoaccepttheplace–ifnot,wecanoffertheplacetosomeoneelse.

How to Enrol:

CONTACT: Ifyouwouldliketofindoutmore,pleasecontactuson:Tel:020 7938 8054Email: summeruni@rbkc.gov.ukVisit:www.summerunilondon.org/kensingtonandchelsea

Summer Uni 4U Registration Form

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Degree Other (please give details)

Name of employer:

Full-time Part-time

Ethnicity: (please circle)BlackAfrican BlackCaribbean BlackOther MoroccanIndian Pakistani Bangladesh AsianOtherChinese White(UK) White(Irish) White(Other)WhiteandBlackCaribbean WhiteandBlackAfrican WhiteandAsian OtherMixed

Religion:

I do not wish to give the information (please circle): Yes No

Unspecified/please state:

My choice of courses:

1: Ref no: SU:

2: Ref no: SU:

3: Ref no: SU:

4: Ref no: SU:

5: Ref no: SU:

Terms and conditions of enrolment (Aged 18 and under):

Tobecompletedbytheparent/carersforparticipantsaged18orunder.Pleasereadthefollowingtermsandconditionsofenrolmentcarefullyandsignbelow:

ByenrollingonthisSummerUni4Uactivityyouacknowledgeandunderstandthat:•Intheeventofanemergency,medicaltreatmentincludinganaestheticmaybeauthorisedonyourbehalfbySummerUnistaffandtheirrepresentatives.

•YourinformationwillberecordedonanelectronicdatabaseandwillbeaccessibletotheorganisationshostingtheactivityandtoSummerUniLondon.

•Activitiesthatyouareinvolvedinmaybephotographed,filmedorotherwiserecordedwiththeintentionthatthematerialsareusedforpromotingtheSummerUni,itspartners,itsparentorganisationandSummerUniLondon.Ifyoudonotwishforyourimagetobeused,youmustnotifytheSummerUni4Ubeforestartingthecourse.

•Anyformofabuseorthreateningbehaviourmayresultinyoubeingexcludedfromanactivityortripandbeingsenthome,thecostofwhichwillbebilledtoyou.

Inaddition,wewouldliketouseyourinformationtofurtherenhancetheservicesweprovideandthataremadeavailabletoyou.Pleasereadthefollowingandindicateifyouarehappyforustouseyourinformationinthiswaybyplacingatickintherelevantbox(notethattheseboxesdonotaffectyourapplication).

•SummerUni4UandSummerUniLondoncanuseyourinformationtosendyoudetailsofotherSummerUniactivitiesthroughadvertisementsandnewsletters.

•SummerUni4UandSummerUniLondoncanmakeyourinformationavailabletocarefullyselectedthirdparties.

DATA PROTECTION NOTICE:ThepersonalinformationthatyouprovideonthisformwillbehandledbytheRoyalBoroughofKensingtonandChelseainaccordancewiththeDataProtectionAct1998.TheinformationthatyouprovideherewillbeusedbytheCommunityLearningDivisionforgeneralregistrationpurposes.Thisinformationwillonlybeusedforthisandrelatedpurposes.

(ThisinformationisrequiredinordertomonitorEqualOpportunitiesPolicy)

Name:

Signature: Date:

(block letters)