Year 13 STEM Academy Summer Project
Queen’s University Belfast in collaboration with FG Wilson (Engineering) Limited
Mon 22 - Fri 26 August 2011

Personal Details PRIVATE & CONFIDENTIAL

Family Name: / First Name(s):
Address:
Postcode: / Telephone Number:
Mobile:
E Mail:
Date of Birth: / Male/Female (Delete as appropriate)
School Name & Address:

Have you attended any events at Queen’s University Belfast?Please give details.

Qualifications up to Year 12

Title of Qualification
(e.g. GCSE / BTEC,OCR) / Year Taken / Subject / Grade / Title of Qualification
(e.g. GCSE / BTEC,OCR) / Year Taken / Subject / Grade

Year 13 and proposed Year 14 course of study

Year 13 / Year 14
Title of Qualification / Awarding Body / Subject / Title of Qualification / Awarding Body / Subject

Subjects of interest: (Please tick)

Science (e.g. Biology, Chemistry, Physics)□Maths□

Engineering (including Product Design)□Computer Science/ ICT□

Do you consider yourself to have a disability?
In accordance with the University’s equal opportunities policy, we would like to ensure that applicants, regardless of disability, can participate fully in the Summer Project. If you indicate that you have a disability we will contact you to discuss any necessary arrangements to enable your participation. / Yes
□ / No
□
Personal Statement
Which careers are of most interest to you?
______
Why are you applying for a place on the Year 13 STEM Academy Summer Project?
______
Please give details of your interests/activities and any positions of responsibility, including part-time work, which you may have.
______
Data Protection
This information will be used by Queen’s University Belfast for the purposes of education and the associated administration (i.e. selection criteria). This information will be retained for a period of three years after your completion of the Summer Project. If you do not agree to Queen’s University Belfast processing this data as defined above, please tick this box. 
Student Declaration
The information I have provided on this form is accurate.
Signature of Applicant: Name (Block Capitals):
Date:
Declaration by parent/guardianof applicants under the age of 18 at start of project:
I agree that ______may attend the STEMAcademy Summer Project atQueen’s University Belfast.
Signature of Parent / Guardian: Name (Block Capitals):
Address: Emergency Contact Number:
Date:
School Reference
How has this student demonstrated the motivation and potential to succeed in Higher Education?
______
I am happy to support this student in their application:
Referee Name (Printed): Signature of referee:
Position in school: Date:

Please return completed application forms to:

Widening Participation and Student recruitment, Rm 02.083 Lanyon North, Queen’s University Belfast, BT7 1NN

Closing date for applications: Monday 27 June 2011