Residential Summer School

3rd 5th July 2013 (3 days & 2 nights)

1. Personal details (please use block capitals) Forename:: Surname:: Address::

3. Do you have any dietary / additional needs e.g. vegetarian?

4. Ethnicity (please tick one box) Postcode:: Telephone:: Email:: College:: Current qualifications being studied: White British Black or Black British Caribbean Asian or Asian British Indian Chinese or other ethnic background Chinese Mixed White and Black African Other ethnic background White Irish Black or Black British African Asian or Asian British Pakistani Other Asian background Other White background Other black background Asian or Asian British Bangladeshi Mixed White and Black Caribbean Other mixed background

Date of Birth::

Gender: M / F

2. Do you have a disability? No known disability Deaf / hearing impairment Blind / partially sighted Wheelchair user / mobility difficulties Mental health difficulties Multiple disabilities

Mixed White and Asian Own description:

Personal care support An unseen disability e.g. diabetes, epilepsy, asthma Autistic A specific learning Spectrum disability e.g. Disorder dyslexia A disability not listed Please advise us of any individual needs below, including medicine or treatment you require during the Summer School:

5. Contact details of next of kin Forename: Surname: Relationship to you Address:

Postcode Telephone:

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6. Family occupation and qualifications Does your mother, father or guardian have a degree or higher education qualification? Yes No

3rd 5th July 2013 (3 days & 2 nights)

10. Why are you interested in applying to the Southampton Solent University Summer School?

Do any of your older brothers and sisters have a degree or higher education qualification? Yes No

Are any of your older brothers or sisters currently studying for a degree or higher education qualification? Yes No 11. Events: There will be a variety of activities during the 3 days, 2 nights. It is important that you read Item 8 and 9 on the code of conduct and use of personal data now. 12. Parent and Student Signature: I consent to the terms of items 8 and 9:

7. What subject tasters are you interested in participating in? You may pick up to three choices Please number your choices* of interest from 1 to 3; 1 is your first choice, 2 is your second choice and 3 is your third choice *(we will then endeavour to offer you an area you are interested in) Art & Design Business & Law Computing Media (Writing and Communication) Media (TV & Film) Social Sciences Sport Tourism

Student signature: Date:

I consent to my child taking part in the Southampton Solent University programme indicated in items 8 and 9. In the event of illness or accident, I consent to any emergency or first aid medical treatment, which might include the use of anaesthetics.

Parent / Carer: Date:

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8. Code of Conduct The following rules apply. By completing and signing this application form both parent and applicant agree to these rules: Students are expected to take part in all timetabled activities. Students are not allowed to leave the University site without permission from University staff. Students are expected to follow any emergency procedure, such as a fire drill, as directed by University staff. Smoking is only permitted in designated areas The possession, sale, purchase or use of any illegal substances is strictly forbidden. Students should not involve themselves in dangerous activities that will cause injury to themselves, other students or staff. No one should engage in abusive or anti-social behaviour towards other students or staff. Additional Rules for Residential Events: There will be separate male and female accommodation. Males and females are expected to keep to their own accommodation area. Participants are expected to be in their rooms at specified times (which will be indicated on the first day). It is expected that the event will be free from serious misconduct or a breach of the rules. However, in the event that it does occur, the student concerned will not be allowed to continue on the activity and arrangements will be made for the student to be taken home. In this circumstance, the cost of transport will be covered by the participants family. 9. Use of Personal data This activity is funded by Southampton Solent University to raise aspirations in young people and make them aware of opportunities available in Higher Education. It would therefore be helpful for us to evaluate our activities by using the information in this application form. Any information provided will be treated in accordance with the Data Protection Act (1998). Permission to hold and use personal data: I agree to the information provided in this form being processed by Southampton Solent University for the purposes of evaluating University widening participation activities. I also agree to the data being made available to members of staff at Southampton Solent University and the Higher Education Funding Council for England (HEFCE), Higher Education Statistics Agency (HESA) and

3rd 5th July 2013 (3 days & 2 nights)

University and College Admissions Service (UCAS) databases on the understanding that no information will be published that could identify me. I have read point 8 and agree to the code of conduct rules set out. I have also read point 9 and agree, on behalf of the named student, to the information provided being processed in the manner described. I have given consent to the college for my child to attend the Southampton Solent University activity and understand that the University will confirm the date the event will take place and any other required information in writing. Under the Data Protection Act (1998) you have the right to a copy of the data held about you by us, for a small fee. If you have any concerns about the use of data for these purposes or would like a copy of the data you have supplied directly to us, please contact Southampton Solent University, East Park Terrace, Southampton SO14 0YN. Southampton Solent University may also contact you from time to time with information regarding other events the University is running. If you do not wish to receive communication please tick here future

Consent for taking images: During the visit the University may take photographs or videos. We would like to use these in presentations, publicity or on websites for educational purposes. If you do not consent for us to take and use images as described please tick here Costs for the event will be met by Southampton Solent University, including food and accommodation, all trips and activities (where appropriate). Completed application forms should be passed either through your college contact by Monday 3rd June 2013 via email or to: Lizzi Brazier A201, Solent Partnerships Team Southampton Solent University East Park Terrace Southampton SO14 0YN Email: summerschools@solent.ac.uk Facebook: SSU Summer School 3-5 July 2013