University of the Arts London by lv6sU7W


									                                       Application Form
                                Art History Summer University

Complete and send your application form, signed by your tutor and parent/guardian as
soon as possible.

Please send it to Alice Odin:


      Post: Alice Odin
      Public Programmes
      Courtauld Institute of Art
      Somerset House, Strand
      London WC2R 0RN

Any further information, please contact Alice on 020 7848 1058.

For more information on this course:

Please complete the ENTIRE FORM and PRINT CLEARLY. Thank you.

First Name:                                   Date of Birth:

Surname:                                      Circle:          Female or Male

Home Address:


Home Phone No:                                 Mobile Phone No:

Email Address: ___________________________________________________

How would you prefer we contact you: by email           or   by post   (Please circle)

Information about your school or college

Name of School / College you are attending:

Address of School / College:

Postcode:                                 Borough:

What courses and subjects are you currently studying? Please list them

Name of your School/College tutor:

Subject your tutor teaches:

Email Address: ___________________________________________________

Contact Details of Parent or Guardian

Name of Parent or Guardian:

Daytime phone number:                       Emergency phone number:

Please describe any medical needs that we should be aware of (e.g. Allergies, Diets
Conditions etc).

Do you have a disability? Yes       No
If yes, what is your disability:

This is a Widening Participation project with specific funding to encourage students from
families who have not previously been to Higher Education to apply to university.
It is therefore important that the section below is completed.

Do either of your parents have university degree qualifications?   Yes / No / Both
(please circle)

Mother/ Guardian yes / no            Father/ Guardian      yes / no        don’t know

What are your parent / guardian’s occupations?
Mother/ Guardian:

Father / Guardian:

Were/Are you (the student) receiving EMA?            Yes                  No
(Education Maintenance Allowance)

Please tell us more about yourself

Why would you like to attend the AHSU (100 - 300 words)?

Declaration Signed by a Teacher
I have checked the details on the application form. I confirm that they are correct and
I support this application.

Name:                                Signature:
Direct Telephone Number and/ or email:

Please add any relevant notes to support this student’s application:

Parents / Guardian Consent
(This section must be completed if the student applying for the course/ summer school is under
18 years of age.)

      I am the parent / guardian of the above young person and I have read and
       understood the notes set out in the supporting information and I consent to
       him/her taking part in the above named course.

Signed:                                           Date:
    I consent to my son/daughter/charge receiving such medical treatment as may
       be advised by a doctor in the event of an emergency.

Signed:                                           Date:
    I consent to my son/daughter/charge to be photographed and I give my consent
       for these photographs to be reproduced in promotional materials and
       subsequently included in Art History Summer University and the Courtauld
       Gallery websites and displays.

Signed:                                             Date:

Student Consent

I confirm that, to the best of my knowledge, the answers I have given on this application form
are accurate. I can confirm that I am available to attend this course.
I would like to apply for a place.

Signed:                                                Date:

Data Protection Act 1998
The Courtauld Institute of Art, London processes data in accordance with the Data Protection Act
1998. The personal information that you provide on these forms will be processed for purposes
connected to the legitimate business of the University and may be transferred between all of the
University departments. Some of the information that you provide on this form may be sent to the
Funding councils, their agents and other statutory bodies for statistical and other purposes,
including the National Student Survey.


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