SUPER – Student Application Form

Contact Details
Name
Address
Home postcode
Date of birth (dd/mm/yyyy)
Contact e-mail address
Contact telephone number
School or college name
SUPER details
Which week are you applying for? (please tick ONE)
4th July – 8th July 2016 11th July – 15th July 2016  Don’t mind 
I am interested in the possibility of a two-week placement: YES  NO 
Please tell us why you would like to take part in the SUPER work experience programme and what you feel you would gain from being involved.
Personal details
Gender / Female  Male  (please tick)
Parent/carer’s occupation / 1) / 2)
Do any of your parents/carers have a Higher Education qualification (i.e. do they hold a degree?)
YES  NO  (please tick)
If YES, please provide details including university attended, course studied and year of graduation (if known)
Do you intend to go to university?
YES  NO  Don’t know yet  (please tick)
What subjects do you think you may be interested in studying at university?
I (the student) consider myself to have a disability
YES  NO  (please tick)
If ticked YES please provide details of the nature of your disability including any additional support you feel you may need while participating in the SUPER programme.
I am a Looked After Young Person (currently living with people other than my parents or
under the care of my Local Authority)
YES  NO  (please tick)
I am a Young Carer
YES  NO  (please tick)
I am eligible for free school meals/the pupil premium
YES  NO  (please tick)
Please choose the category which you feel most closely resembles your ethnic origin
() / ()
White / Other Asian background
Gypsy or Traveller / Mixed – White and Black Caribbean
Black or Black British – Caribbean / Mixed – White and Black African
Black or Black British – African / Mixed – White and Asian
Other Black background / Other Mixed background
Asian or Asian British – Indian / Arab
Asian or Asian British – Pakistani / Other Ethnic background
Asian or Asian British – Bangladeshi / Not known
Chinese / Prefer not to say
Other – please give details

If your application is successful, to enable you to take part we need to ask for some information for our programme records, as well as relevant permissions, as outlined below. Please note that we need this information to verify your eligibility to take part in the programme, and if you do not provide all of the details requested this may affect your participation.

The applicant.
I confirm that I understand the nature and expectations of the programme I am applying for.
I confirm that I will attend all scheduled activities in EITHER week 1 (04/07/16-08/07/16) or week 2(11/07/16-15/07/16) unless there are special circumstances that prevent me from doing so.
I give permission for the data gathered about me as part of this application process to be passed onto the University of Sheffield and stored securely.*
If I am successful in gaining a place on the programme:
I give my consent to feature in any photos or videos that may be published as promotional or PR materials for the Project, e.g. in PowerPoint presentations, leaflets, brochures, on the University website or in local, national or world-wide press releases, without restriction.
I consent to evaluate the activities I take part in, complete update requests and other studies (e.g. surveys or research activity) that may be requested during my time on the programme and subsequent interactions.
I give my consent to share my personal details with relevant departments at the University of Sheffield in order that any future application to study at the University of Sheffield may be considered in light of my participation in a University of Sheffield outreach programme.
If I wish to opt out of any of the above, I understand that it is my responsibility to inform the SUPER coordinator of my decision.I understand that this will not result in any repercussions for me.
Applicant signature
Please print name / Date
The parent/carer
I confirm that I understand the nature and expectations of the programme that my son/daughter/the young person in my care is applying for and give my permission for them to participate.
I give permission for the data gathered about my son/daughter/the young person in my care as part of this application process to be passed onto the University of Sheffield and stored securely.*
If my son/daughter/the young person in my care is successful in gaining a place on the programme:
I give consent for them to feature in any photos or videos that may be published as promotional or PR materials for the project, e.g. in PowerPoint presentations, leaflets, brochures, on the University website or in local, national or world-wide press releases, without restriction.
I consent to allow my son/daughter/ the young person in my care to evaluate the activities they take part in, complete update requests and other studies (e.g. surveys or research activity) that may be requested during their time on the programme and subsequent interactions.
I give consent to share my son’s/daughter’s/ the young person in my care’s personal details with relevant departments at the University of Sheffield in order that any future application to study at the University of Sheffield may be considered in light of their participation in a University of Sheffield outreach programme.
If I wish for my son/daughter/the young person in my care to opt out of any of the above or to leave the programme I understand that it is my responsibility to inform the SUPER coordinator of this decision.I understand that this will not result in any repercussions for me or my son/daughter/the young person in my care.
Parent/carer signature
Please print name / Date

*Data Protection: The data collected here will be processed by the University of Sheffield in accordance with the Data Protection Act 1998 and held for an extended period of time. For research, monitoring and evaluation purposes only, your data may also be shared with appropriate third party organisations such as the Higher Education Funding Council for England, Higher Education Statistics Agency and our partners including Higher Education Access Tracker Service subscribers. We will not release data to anyone who is unauthorised. Under the Data Protection Act 1998 you have the right to a copy of the data held about you by us. If you would like a copy of the data you have supplied to us, please contact . By submitting your application, you are consenting to the use of your data as outlined above.
If you do not wish to be contacted by the University of Sheffield about future activities, please tick here ☐
As part of this application, we have collected data regarding ethnicity, disability and health and social care for monitoring equality of opportunity under the Equality Act 2010. Please tick here if you are happy for this information to also be used for evaluation and monitoring purposes☐