1. Healthcare

LSE Year 11 Summer School 2015
6-10 July 2015
Deadline for application: Friday 6 March 2015
First Name
Surname
School
Checklist: Please tick to ensure you have completed the form correctly
Student:
I can attend each day of the summer school
I have completed all information in sections A, B, C and D
I have written a personal statement in Section C
I have signed in Section D
Parent/Carer:
I have completed Section E and signed to give my consent
Teacher:
I have given a reference in support of this application in Section F and signed to confirm the details provided are correct
Please note: If incorrect information is found to be submitted in order to favour the application this will result in
withdrawal from the programme.
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LSE Year 11 Summer School 2015
6-10 July 2015
Completing this form
You need to complete Sections A, B, C and D in BLOCK CAPITALS. Then pass the application to your parent/carer
who must complete Section E. Then hand to your teacher who needs to complete Section F. They will then return the
application form to us on your behalf.
Section A – Personal Information Please complete in BLOCK CAPITALS
Surname (as it appears on passport):
Date of Birth:
First Name (as it appears on passport):
Gender:
please tick
Male
Female
Known as:
Address:
Postcode:
Telephone Home:
Mobile:
Email address: (Required)
Ethnic Background
Please indicate which ethnic group you belong to by ticking
one box.
C – Asian/Asian British
A – White
English/Welsh/Scottish/Northern Irish/British
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background, please specify:
Irish
Gypsy or Irish Traveler
Any Other White background, please specify:
D – Black/African/Caribbean/Black British
African
Caribbean
Any other Black/African/Caribbean background, please specify:
B – Mixed/multiple ethnic groups
White and Black Caribbean
White and Black African
E – Other ethnic group
White and Asian
Arab
Any other Mixed/multiple ethnic background, please specify:
Any other ethnic group, please specify:
F
Not Known/ Not Provided
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Disability
Do you consider yourself to have a disability? Please tick. If yes, please provide details
Yes
No
Do you live under local authority care (eg, in foster care or a care home) Please tick
Yes
No
Are you eligible for free school meals?
Yes
No
Section B – Academic Information
Please list all your predicted GCSE subjects and grades.
Please let us know the subjects you are considering for AS level.
Have you ever attended a university summer school before?
Yes
No
If yes, please detail when and where
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Section C – Year 11 Summer School
Personal Statement
Please tell us why you wish to take part in the LSE Year 11 Summer School.
Please use all the space provided.
Please try to cover the following in your personal statement:
• Your reasons for wanting to take part
• What you think you will gain from the summer school
• What you hope to do in the future.
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Section D – Future Plans
What do you plan to do after you have completed your GCSEs? please tick one box
AS and A Levels
International Baccalaureate (IB)
Get a job
Training for a specific career
Other please specify:
Have you thought about going to university when you leave school/college?
Yes, I want to go
I’m not really sure
No, university’s not for me
(By signing below you consent to information regarding the content and status of your application being shared with your school. You also consent to us
contacting you about the summer school by text message)
Student signature
Section E – Consent
Date
This section MUST be completed by a parent or carer.
Parent/carer 1
Parent/carer 2 (if appropriate)
Name:
Name:
Relationship to applicant:
Relationship to applicant:
Occupation:
Occupation:
Email address:
Email address:
Are you registered as unemployed or seeking work?
Is this person registered as unemployed or seeking work?
Yes
Yes
No
Have you attended university?
Has this person attended university?
No
Yes
No
Yes
No
If you have answered yes to the question
above please fill in the fields below
If you have answered yes to the question
above please fill in the fields below
Name of university:
Name of university:
Course:
Course:
Qualification received:
Qualification received:
DECLARATION TO BE SIGNED BY A PARENT/CARER
I have completed the form with the information to the best of my knowledge.
The UK Data Protection Act (1998) requires us to obtain your explicit consent to process and retain your son’s/ daughter’s data as supplied on this
application form. We will process this data in accordance with these principles. The data will be used and securely retained by LSE in order to process this
application and to evaluate the project. Our sponsors may wish to contact your child for marketing purposes. We will only pass the details on if consent
has been given. We will NOT USE the data provided for marketing purposes or give the data to any third parties if permission has not been granted.
Please tick this box to confirm that you give consent to the above use of data. Please contact [email protected] if you have any concerns.
PUBLICITY DISCLAIMER
This event may be recorded and photographed solely for record and future publicity purposes by LSE and its agents, Please understand that by submitting this
application any applicant, (or parent/guardian of an applicant) is agreeing for their image to appear in LSE printed publicity and promotional material and on the LSE
website. If you have any objections to your son’s/daughter’s image being used for the above purpose please do not give consent for the application to be submitted.
I am the applicant’s legal guardian
Yes
No
I give permission for this application for my son/daughter to attend the LSE Summer School
Signature of parent/carer:
Date:
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Section F – School
This section MUST be completed by your school.
Name of School
School Postcode
Borough
School Statement
Please write a short statement outlining why this student should be considered for a place on the LSE Summer School.
Please refer to the notes on the Teacher Information Sheet to complete this statement.
Please ensure that your statement in support of this application is personal as giving a generic statement will put the student
at a disadvantage.
Declaration of Support (to be signed by a teacher)
I have checked the details on this application form and can verify the predicted grades in section B and all details
are correct. Please note applications which do not meet the eligibility criteria, or are incomplete will be returned
to the signatory without consideration.
Tick
Name:
Position:
Teacher signature:
Named school contact for applications
(if different from above):
Date:
Telephone:
Email:
*INFORMATION FOR TEACHERS*
Once all sections have been completed, please return to:
Year 11 Summer School Co-ordinator, Student Recruitment Office,
The London School of Economics and Political Science, Houghton Street, London WC2A 2AE
DEADLINE FOR RECEIPT OF APPLICATIONS is Friday 6 March 2015.
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