Summer University 2012 Enrolment Form

PLEASE COMPLETE THIS FORM IN BLOCK CAPITALS

Personal Details

Q1	First Name (s):

Q2	Surname Name:

Q3	Date of Birth (DD/MM/YYYY):

Q4	Age: Enter number only

Personal Details - Continued:

Gender:

Male

Femaie

Q6	Address:

Q7	Post Code: E.g. SW9 0TX

Contact Details

Q8	Home Telephone/Mobile:

Q9	Email:

Q10	Name of school, college or other educational establishment that you attend:

Medical History

Q11	Please give any details of any medical condition: E.g. Diabetes, epilepsy, allergies etc

Q12

Do you have any learning difficulties or disabilities?

Yes

If Yes, please give details:

Q13

Do you have any special requirements?

Yes

If Yes, please give details:

COURSE INFORMATION

Please enter 3 course choices you would like to register for (in order of preference). Please see the attached document for full details of summer university 2012 courses.

Preference 1/Course 1

Q14	Course Code:

	Name of Course:
	Course Start Date (DD/MM/YYYY):
	Course End Date (DD/MM/YYYY):

Preference 2/Course 2

Q15	Course Code:

	Name of Course:
	Course Start Date (DD/MM/YYYY):
	Course End Date (DD/MM/YYYY):

Preference 3/Course 3

Q16	Course Code:

	Name of Course:
	Course Start Date (DD/MM/YYYY):
	Course End Date (DD/MM/YYYY):

Q19

I understand that for the groups and my own safety I will agree to obey the rules and instructions of members of staff
Please tick one only

I agree

I don't agree

Thank you for completing this form online for Summer Holiday Activities (HAP) and Summer University (SU) 2012.

Click 'Submit' to send your completed form.

Summer University 2012 Enrolment Form

PLEASE COMPLETE THIS FORM IN BLOCK CAPITALS

Thank you for completing this form online for Summer Holiday Activities (HAP) and Summer University (SU) 2012. Click 'Submit' to send your completed form.

Thank you for completing this form online for Summer Holiday Activities (HAP) and Summer University (SU) 2012.

Click 'Submit' to send your completed form.