Middlesex University - University of Northern Colorado
Transcription
Middlesex University - University of Northern Colorado
Middlesex University Summer School Application Form This form is to be used for Summer School applications only * fields are mandatory Admin Staff (for Office use only): ______________________________________________________________ Personal details (As they appear on your passport/driver's licence or other official ID) Family name: First name(s): Previous name: Gender Male Date of Birth: (DD/MM/YY) Female Title: (Mr/Ms/Miss/ etc) Correspondence address: Postcode/zip code: Country Tel No: Mobile E-mail: Academic details Applicants for credit bearing courses only: If you are currently a student at a university or college other than Middlesex University please complete the following section: Name of Partner Institution Baylor University Birmingham-Southern College CAMPUS 02 CUNY, College of Staten Island Fulton-Montgomery Community College Iowa State University Northeast Community College Plymouth State University University of Northern Colorado CUNY Baruch College Towson University University of St Josephs Macau SUNY Brockport SUNY Purchase SUNY, New Paltz Other If selected other above (Please specify) Name of Sponsor or Company: Programme title: Do you wish to undertake assessment for academic credit? Yes No Do you require summer school credits to count towards your degree? Yes No Courses applied for Title 1 Course Code: Title 2 Course Code: Alternative course: Title 1 Course Code: Title 2 Course Code: Summer Package Students from partner institutions please indicate whether you will be joining our 3 or 5 week package 3 week Package 5 week Package Please note that tuition, accommodation and social and cultural programme are included in the package. If you are not from a partner institution but would like to join one of our summer packages please tick one of the above Highest qualification Please detail the highest level of education completed e.g. GCSE, A' Level, Diploma, BA, MA etc Qualification Type: Name of institution and country: English language qualifications Please note that students who are studying courses other than English Language courses are required to have IETLS 6.0 or the equivalent if English is not their first language. Qualification Name: Grade Achieved: Award Date Disabilities or special needs The University encourages you to disclose any disability/medical condition which could disadvantage your ability to study. The information you submit will be used to help Middlesex University provide appropriate support and will not affect your application. Please choose all that apply. This is a mandatory section No disability (0) Dyslexia (1) Blind/partially sighted (2) Deaf/hearing impairment (3) Wheelchair user/mobility issues (4) Personal care support (5) Mental health difficulties (6) Unseen disability: e.g. Diabetes (7) Autistic Spectrum/ Asperger's (T) Other If your disability is not mentioned above and you have ticked other then please specify: Please mention any other additional support needs (if required): Accommodation Accommodation is included in our summer packages. If you are not joining one of these, you will receive information about accommodation options separately. Fee Payment Please provide details of how your fees will be paid: Baylor University Birmingham-Southern College CAMPUS 02 CUNY, College of Staten Island Fulton-Montgomery Community College Iowa State University Northeast Community College Plymouth State University University of Northern Colorado CUNY Baruch College Towson University University of St Josephs Macau SUNY Brockport SUNY Purchase SUNY, New Paltz Other If you ticked Sponsor or Employer above then please specify the name: Country of permanent residence: Country of Birth: Nationality (as on Passport) Have you ever lived outside the UK/EU? Yes No Yes No If yes, Where: Have you entered the UK on a Visa? Last date of entry to the UK/EU: Please note that successful applicants will only be issued an unconditional offer letter, required for some Visas, once full payment has been received Please state below how you heard about Summer School: Achievement Officer Communications Direct mailing - Email EU Portals Floodlight Google Search Hot Courses Middlesex University Admission Middlesex University Alumni Website Middlesex University Lecturer Middlesex University Regional Office Newsletter Previous Summer School Student Study abroad office Study abroad Fair Summer School Website UNIHUB Other If you ticked other above then please specify below: Ethnic origin and equal opportunities monitoring The University is committed to providing equal opportunities for all. To assist us with our monitoring please choose one of the boxes below. This form will be separated from your application and the information supplied will be recorded on our computer system for statistical monitoring purposes. This information will not be considered as part of the admissions process. This is a mandatory section British (11) Caribbean (21) Indian (31) Irish (12) African (22) Pakistani (32) Scottish (13) Other Black Background (29) Bangladeshi (33) Welsh (14) White & Black Caribbean (41) Other Asian Background (39) Other White Background (19) White & Black African (42) White & Asian (43) Chinese (34) Other Mixed Background (49) Not Known (90) Information Refused (98) Declaration of criminal record In an effort to help the University reduce the risk of harm or injury to their staff and students caused by the criminal behaviour of other students we must know about any relevant criminal convictions an applicant has. In this matter relevant criminal convictions are deemed only to be those convictions for offences against a person, whether of a violent or sexual nature and convictions for offences involving unlawfully supplying controlled drugs or substances where the conviction concerns commercial drug dealing or trafficking. Convictions that are spent, (as defined by the Rehabilitation of Offenders Act 1974) are not considered to be relevant and you should not reveal them, unless you are required to complete an ‘Enhanced Disclosure Document’ from the Criminal Records Bureau or the Scottish Do you have a relevant unspent criminal conviction? Yes No If you have ticked Yes, please disclose details of your offence and conviction, including dates and courts convicted at. This information should be submitted along with your application form in a separate sealed envelope, clearly marked confidential with your name and date of birth on it. If you will be sending this form via email then alternatively you can send us a word file along with your application via email and can be sent directly to [email protected] clearly marked confidential with your name and date of birth in the email header. Any information disclosed will be handled and disposed of securely by Middlesex University in compliance with the Criminal Records Bureau Code of Practice, the Data Protection Act and other relevant legislation. If you are convicted of a relevant criminal offence after your application has been submitted, you must notify us. The university may request further disclosure from you and your offence may affect your application. Declaration I confirm that the information given in this form is true, complete and accurate: no information requested or other material information has been omitted. I consent to the processing of this data by Middlesex University for educational purposes under the provision of the 1998 Data Protection Act. I understand that if studying a course with an exam assessment element it is my responsibility to be available to attend on 3 August 2015. I understand that Middlesex University reserves the right to cancel or amend Summer School courses for reasons of viability or due to any other unforeseen circumstances, in which case any fees paid will be refunded in full. Please tick to confirm that you have read the above declaration * Signature/Name: Date (DD/MM/YY): If you are not applying through a partner institution, please scan or post this completed form to: Summer School Office, Middlesex University, The Burroughs, London, NW4 4BT, United Kingdom Tel: +44 (0)20 8411 5782 Email: [email protected] Web: www.mdx.ac.uk/summer