Thank you for expressing an interest in attending Sample MedicineSaturday 4th October 2014 from 9:00 am until 3:30pm at the Robert Kilpatrick Clinical Sciences Building on the Leicester Royal Infirmary site.
Please complete the following form to confirm that you wish to be considered to attend the event. Sample Medicine is supported by the University of Leicester Widening Participation Impact Pot and therefore those from disadvantaged backgrounds will be prioritised when selecting participants. You must have returned this application form to Monday 22nd September 2014 and you will be informed whether you application has been successful by Friday 26th September.
Should you be selected for the activity, the information included in this form will be used to evaluate the activity. This will involve sharing your information with the East Midlands Widening Participation Research and Evaluation Partnership.
Name:Date of Birth: / D / D / M / M / Y / Y / Y / Y
/ Year Group:
Home Address:
Home Postcode: / Sex: / Female Male
Email Address:
School / College:
Educational background of parents/carers
Have any of your parents or carers been to university or taken a degree?
Yes No Don’t know
Parental/carer occupation - we would like to know the following information for research purposes only:
Please think about which of your parents or carers currently living in your home earns the most money. What is their job?
Ethnicity (please tick one):
Chinese
Bangladeshi
Indian
Pakistani
Other Asian Background / Black Caribbean
Black African
Other Black Background
White
White & Asian / White & Black African
White & Black Caribbean
Other Mixed Background
Other Ethnic Background
Prefer not to say
Disability (please tick):
No known disability
Dyslexia or other learning need
Blind/partially sighted / Deaf/hearing impaired
Wheelchair user/mobility difficulty
Mental health difficulty
Unseen disability / Multiple disabilities
Autistic Spectrum Disorder / Asperger’s Syndrome
Other disability
Prefer not to say
GCSE Performance
Please answer the following questions about your performance in your GCSEs
What grade you receive in your English GCSE?
What grade did you receive in your Mathematics GCSE?
What science courses did you sit for your GCSEs (i.e. Double Award or single subject courses)? Please list the grade you received for each GCSE course.
Please list the grades you received in your other GCSEs
Photography
University of Leicester sometimes use photography for publicity purposes. We would like your permission to photograph you for possible use in our publications, website and other publicity material. They may also be used by our partner organisations (noted above) with our permission. The image(s) will remain the property of the university providing the activity and will be used for the sole purpose of promoting similar activities.
I agree* / do not agree* to having my photograph taken
(* please delete as appropriate)
Further Contact
From time to time we may send information to you that we feel is useful, including university/education information or more opportunities to take part in activities. We may also wish to make contact for further research purposes.
I agree* / do not agree* to being contacted by the partners mentioned above (* please delete as appropriate)
Data Protection
In order to ensure that our activities are effective and reaching the right people, we collect and analyse statistical information, including information about your ethnicity and disability statement. The research is being undertaken in partnership with universities in the East Midlands, the Higher Education Funding Council for England (HEFCE), the Universities and Colleges Admissions Service (UCAS), the Higher Education Statistics Agency (HESA), Connexions and the school or college’s Local Authority.
Any personal data we collect is confidential and will only be shared with the partners mentioned above and will not be used for any other purpose. Data will be processed in accordance with the Data Protection Act 1998. For more information, please see or call 01509 223462.
PLEASE COMPLETE THE INFORMATION BELOW
Signature (please type):
Date:
If you do not give your consent for the information collected on this form to be used in the above mentioned research, then please tick this box