Application for Admission as an Incoming Study Abroad Student: Carleton in Venice Programme(for autumn term 2015)

About You

Title -- Mr / Mrs / Miss / Ms / Dr / Professor / Reverend
Surname/family Name *

Forename/given name (in full) *

Other name(s) (if applicable) *
Informal Name (if different)*
Date of birth dd/mm/yyyy *
Gender * Male Female Trans/Unknown
Please enter your passport number (if known) *
Have you ever been a student at Warwick before? * Yes No Please enter your previous Warwick ID number (if known) *

Course Details*

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Communicating with you

Permanent Address

Is your permanent home address in the UK or Non-UK? *
List your full permanent address*
Permanent Mobile/ Cell phone *
Permanent Telephone (including country code) *
Permanent Fax (if any) *
Permanent Personal Email *

Correspondence address (Please complete this section if it is different from above.)

Is your correspondence address same as your home address * Yes / No

If not, is your correspondence address in the UK or Non-UK? *

List your full correspondence address*

Correspondence Mobile/ Cell phone *

Correspondence Telephone (including country code) *

Correspondence Fax (if any) *

Correspondence Personal Email *

Is this address temporary? Yes / No *
Please specify the from and to dates when the address will be in use *
From Date (dd/mm/yyyy) * To Date (dd/mm/yyyy) *

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Next of kin details (this should be someone you would like us to contact in the event of an emergency)

Surname *

First Name *

Titles *

Relationship to you *

Telephone (including country code) *

Email address *

Nationality and residence details *

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Academic qualifications

Name of home institution *
Start date (dd/mm/yyyy) *

Qualification to be obtained (e.g. BA/ BSc etc): *

Main subject of your present degree *

Expected grade/ classification/ GPA/ percentage *

Venice option choice (please tick one only):

Art in Venice and Northern Italy 1100-1600

Colour and its Meanings

Personal Statement (in no more than 150 words, please state what this term in Venice will bring to your studies; please state if you have studied abroad previously):

Please ensure that you attach scanned copies of all the following documentation to this application form. Please do not send any original copies in the post.

1. A scanned copy of the personal details page of your passport.

2. A copy of your University transcripts.

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Special Needs

It is helpful to know about any special needs in advance of your study period so that we can discuss whether facilities are available.

Do you have any disabilities/special needs/medical conditions * Yes / No
If you have special needs then please indicate your medical condition(s) *

Are you a registered disabled person * Yes / No

If yes, please give details*

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Declaration

Name *
Date *
The application must be submitted by 13 March 2015 to Mrs Julia Brown (by email as a pdf file: ) with the subject line: Carleton in Venice.Before submitting the application form, please read the following paragraphs carefully:

By submitting this form, you are saying that the information that you have provided is accurate and complete, and that you agree to abide by the rules of the University.

Any offer of a place that you may receive is made on the understanding that, in accepting it, you agree to abide by the rules and regulations of The University of Warwick.

* indicates a required field Privacy statement. In pursuance of the prevention of fraud, the University reserves the right to disclose information that is given in your application form to outside agencies, e.g. o the Police, to the Home Office, to Local Authorities, to Examining Boards, to the Department of Social Security, or to the Student Loans Company. The University reserves the right, at any time, to request that you, your referees, or your previous education institution(s), or your employer(s), provide further information relating to any part of your application form, e.g. proof of identification, of status, of academic qualifications, and/or of employment history.