E:Mail:
Fax:Telephone: 020 7589 1120
Post:Queen Alexandra’s House, Kensington Gore, LONDON SW7 2QT
Please fill in this form and return it to us by e:mail or post.
Your application must be accompanied by a current photograph and a deposit of £300.00 (If applying by post, please include a cheque for your deposit, otherwise we will send you details upon receipt of your application on how the deposit can be paid)
First Name:Surname:
Date of birth:
Will you be under 18 years of age at proposed date of entry to QAH: Yes / No
Nationality: Passport Number:
Home address (including post code):
Contact address (including post code):
Personal telephone number:
Personal E:Mail address:
Fax number:
Proposed college:
Subject and length of course:
Music students, please name your instrument/s:
QAH requires a 36 week accommodation Licence Agreement – you are required to commit to staying and paying for a minimum of 14 weeks in the Autumn term, a minimum of 12 weeks in the Spring term and a minimum of 10 weeks in the Summer term. Any extra days beyond the minimum limits are charged pro-rata.
Grade/size of room required: (please circle one only)
A B C
Proposed date of entrance to QAH:
Name of Parent/Guardian:
Address of Parent/Guardian:
Telephone number of Parent/Guardian:
E:Mail for Parent/Guardian:
If your Parent/Guardian IS RESPONSIBLE for the payment of your residential fees,they must sign and date the following declaration:
I declare that as the above-named Parent/Guardian of
……………………………………………………………………………………(enter full name of proposed resident),
I have read, understand and agree to the terms and conditions as set out in the Queen Alexandra’s House Accommodation Licence.
…………………………………………………………………… ………………………………………………..
(Parent/Guardian signature) (Today’s Date)
Address : ………………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………………………….
If your Parent/Guardian IS NOT RESPONSIBLE for the payment of your residential fees,you must be 18 years of age or over and personally sign the following declaration:
I ……………………………………………………………………………………(enter your full name) as aproposed resident at Queen Alexandra’s House, have read, understand and agree to the terms and conditions as set out in the Queen Alexandra’s House Accommodation Licence.
…………………………………………………………………… ………………………………………………..
(Proposed resident’s signature) (Today’s Date)
Address: …………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………..
Name and address of two referees (e.g. Teacher, House Mistress, Family Doctor or Parish Priest):
Referee 1: Referee 2:
Referees address: Referees address:
Details of any disabilities, serious allergy, regular medication or special diets:
Please include any further information you feel is relevant to your application:(e.g. previous educational establishment, recent educational/professional qualifications and/or employment, main interests, and languages spoken).
Priority given to students of art, music and science