English for Medics Summer School
Application form 2017
PleasecompleteallpartsofthisapplicationforminBLOCKCAPITALS
1. PERSONALDETAILS
Title(Mr/Miss/Mrs/Ms/Dr):Familyname: Firstname: HomeAddress:
Country:
Email:Telephonenumber:
(Wewillemailbooking/paymentconfirmationandoffer lettertothisaddress,pleaseensurethatitiswrittenclearly)
Date of birth: | D | D | M | M | Y | Y | Y | Y |
Gender: Male / Female
Nationality (as per the passport you are travelling on):
Passport number (as per the passport you are travelling on):
DoyouholdavisaforstudyintheUK?Yes No Ifyes,pleasestatetype: * Visanationalstudentsshouldsupplyuswithacopyoftheirvisa,ideallyat least oneweekbeforetravelling.
2. LANGUAGE AND ACADEMICREQUIREMENTS
Pleaseprovide ONE of the certificate details below:
IELTS: Test Report Form (TRF)number:
Cambridge CAE/CPE: Candidate ID number (3 letters & 6numbers):Secret number (4numbers):
Other exam (please specify): Score:
Official certificate from your university/High School
Certificate name: Score:
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Pleasegivedetailsofyoureducationalbackground,includingcurrentstudyanddegreesachieved:
(Please circle one from the list below)
StudyingforBachelor’s ddeDegree / Bachelor’sDegree / Studying for Master’s Degree / Master’s DegreeStudyingforPhD / PhD / Othergraduateprogramme / Other
Please give details of your status: Student Employed Retired Academic
Other Profession:
Ifyouarecurrentlyastudent,pleasestatetheinstitution,courseandyearofstudy
(egUniversity of Leicester, Physics,2ndYear):Institution:
Course:Year(ie1st,2ndetc):
3. DIETARYREQUIREMENTS
Please indicate any specific dietary requirements:
4. SUPPORTREQUIREMENTS
Doyouhaveanyadditionalrequirements,inrelationtoyourlearningoraccesstoyourprogramme,thatyouwouldlikeustohelpyouwith,ifweareabletodoso?Yes No Ifyes,wewillcontactyouforfurtherdetails.
Please describe any special circumstances (e.g. a medical condition) that could affect your ability to do the
progoramme. For medical conditions, you will be required to provide a medical certificate.
5. EMERGENCY CONTACT DETAILS
PleasegivedetailsofsomeonewecancontactinanemergencywhileyouareinLeicester:
Name:Telephonenumber:Emailaddress: Contactaddress:
6. PAYMENT DETAILS
Please choose one of the payment methods from below and tick the box:
Cheque (please make payable to “University of Leicester”)
On-line payment (Please indicate if you would like to pay by credit card)
Cheques can also be sent to the address below with your acceptance form (do not post cash).
English Language Teaching Unit (ELTU)
University of Leicester
Grond Floor, Readson House
96-98 Regent Road
Leicester LE1 7DF, UK
7. APPLICANT DECLARATIONI agree to follow the rules and regulations of this programme.
I have read and agree to the exam conditions below.
I understand that ELTU do not process the acceptance form until they receive the full payment of the course.
Applicant’s Signature:Date:
8. PROGRAMME CONDITIONSIf any of your contact details change, you must contact the English Language Teaching Unit at the University of Leicester immediately.
Once the programme fee has been paid, no refunds can be considered under any circumstances after 20 July 2017unless a medical certificate is provided.
If there are any special circumstances, such as a medical condition, that could affect your ability to do the programme, you should inform us immediately in the Support Requirements section on this form.
You will receive an offer letter for your visa (if applicable) once the payment is settled.
For any further information or queries about the programme, please contact:
Micki Wagner
English Language Teaching Unit
Readson House
96-98 Regent Road,
Leicester, LE1 7DF
Telephone Number:0116 229 7857
Email:
For Office Use:Amount received:Receipt Number:
Date:Taken by (Initials):