Bexley Easter and Summer University 2008

Enrolment Form

Please fill in the details carefully, making sure that dates and times do not clash and the course codes are correct. Most courses are free, however some are at a charge. All payments will be made by you to the organisation who are running the course when they contact you to confirm your place.

Most courses last a week and several run in the mornings or afternoons only, so check the times and that you are available to join in.

You will be required to produce two passport size photographs or present valid photo I.D to the organisation two weeks prior to the course commencing.

General Information:

First Name:
Surname:
Address:
Postcode:
Telephone:
Mobile:
Gender:
Date of Birth:
Age:
Email:

Course Information:

Which course(s) would you like to attend:

Course(s):	Ref:	Date(s):

What are you currently studying?:
	GCSE A Level NVQ or Degree Not currently Studying
If you are currently studying, please name your school or college:

Are you working? (leave blank if not applicable):
	Full Time Part Time Registered Unemployed Unemployed but not registered
What other courses could help you in the future to meet your work/personal goals?:

Parental/Carer Permission

Students under 18 require parental/carer permission

On reciept of your online booking form we will foward you a permission slip to sign if the young person is under 18 years of age.

Please can the parent/carer of the student fill in their details below

Parent's First Name:
Parent's Surname:
Parent's Address:
Post Code:
Parent's Email:
Telephone:
Mobile:
Work Number:	Ext.
(Work number will only be used in an emergency)

Medical Details

Doctor's Name:
Doctor's Address:
Doctor's Telephone:
Do you have a disability?:	Yes No
Please state any access needs you may require:

Please list any medical conditions, allergies or medication which staff should be aware of:

Other Information

Ethnicity:
How did you find out about "Summer Uni"?:
	Family Information Service Internet Friends/Family Youth Club School College Connexions leaflet/advertisement Other (please specify):
Photography We may take photographs or other forms of media (e.g. film or voice) during our courses for marketing, evaluation and to display on our website to promote what we do. We need your permission if you are over 16, or your parent's permission if under 16, to take and use these images. Please tick here if you DO NOT wish your photograph/your child's photograph to be taken or used for the purposes mentioned above