ON TRACK TO BATH
CHECKLIST!
Please make sure all 3 sections are filled out and signed
 Students: Complete SECTION 1. Please check with your parent/carer that you will be free to attend
and make sure you sign at the end of the section.
 Parent/Carer: Complete SECTION 2. Please ensure your parent/carer signs the declaration as the
application cannot be processed without their consent.
 Teacher: Complete SECTION 3. Please ensure your teacher signs the declaration as the application
cannot be processed without their consent.
Closing date for applications to be received by Wednesday 15th October 2014
Please return your completed form to Hilary Brummitt at the address below.
SECTION 1: TO BE COMPLETED BY THE STUDENT
(IN BLOCK CAPITALS)
Name:
School:
Home address:
Town/city
Postcode:
Home phone number:
Mobile phone number:
Email address:
University Contact Details
Sam Wenman
University of Bath
WP Outreach Programmes Manager
Hilary Brummitt
University of Bath
WPO Event Co-Ordinator
Widening Participation Office
Wessex House 5.7
University of Bath
Claverton Down
Bath BA2 7AY
Widening Participation Office
Wessex House 5.11
University of Bath
Claverton Down
Bath BA2 7AY
Tel: 01225 384832
Fax: 01225 386849
Tel: 01225 386587
Fax: 01225 386849
Email: [email protected]
Office use only
Date received: ____________________
Gender:
Male

Female

What Ethnic Group do you belong to?
 White
 White Irish
 Other white background
 Black or Black British – Caribbean
 Black or Black British – African
 Other Black Background
 Asian or Asian British – Indian
 Asian or Asian British – Pakistani
Date of birth (D/M/Y):
Asian or Asian British – Bangladeshi
Chinese
Other Asian Background
Mixed –White and Black Caribbean
Mixed –White and Black African
Mixed –White and Asian
Other Mixed Background
Other Ethnic Background
Not Known









Please give details of your grades achieved at GCSE:
Subject:
Grade:
Please give us details of the subjects you are currently studying:
Subject:
Exam Board:
Please tell us what degree/subject area you are interested in studying at university and why:
Please tell us why you would like to attend On Track to Bath and how it would benefit you:
Please indicate which Track you are interested in.:
 Computer Science Track
 Social Science Track
 Science Track
 Business and Management Track
I declare the information I have given is true and to the best of my knowledge.
Signature of student:
_________________________
Thank you for completing section 1.
Date: ___________
Please hand this application form to your parent/carer to complete section 2.
SECTION 2: TO BE COMPLETED BY THE PARENT(S) / CARER(S)
(IN BLOCK CAPITALS)
First Parent/Carer (to be completed by the main
wage earner
in the student’s household).
Name:
__________________________________________
Relationship to student:
Second Parent/Carer (If information is provided
here the second signature box at the end of Section
2 must be completed).
Name:
__________________________________________
Relationship to student:
Daytime contact phone number:
Daytime contact phone number:
Alternative contact (eg mobile):
Alternative contact (eg mobile):
Email :
Email:
Have you completed a course of Higher Education Have you completed a course of Higher Education
in the UK or abroad?*
in the UK or abroad?*
Yes No 
Yes No 
Are you: (Please tick the appropriate box)
Are you: (Please tick the appropriate box)

Employed

Employed
Please state your occupation ____________________ Please state your occupation ____________________

Unemployed

Unemployed

A full time student

A full time student

Other

Other
Does your son or daughter have any of the following? (please tick)
Note: This information will only be used to help us provide the most appropriate service for your son’s or
daughter’s needs.
Medical conditions
Yes

No

Disabilities (including specific learning difficulties such as
Yes

No

Allergies
Yes

No

Special Requirements (e.g. diet)
Yes

No

Dyslexia, Dyspraxia or Dyscalculia)
If you have answered yes to any of the above, please give details:
* By Higher Education we mean studying in a university, polytechnic, institute of higher education, college or workplace for a qualification such as a BA or BSc Degree, HNC or HND, Foundation Degree or similar
Important:
Please read and sign the declaration
Declaration
Marketing
During On Track to Bath events and activities photographs and video/digital footage of your son/daughter
participating in activities may be taken. We would hope, in this way, to be able to give your son/daughter a
reminder of their experience. We may also wish to use this material, with no names attached, to encourage
other young people to take part in similar events and activities.
If you do NOT wish your son’s/daughter’s image to be used in this way, please tick 
Data Protection
The information you and your son/daughter provide will be processed to assess your son’s/daughter’s
eligibility for the programme. We would also like to create a student record for him/her. We use this for two
reasons: to analyse and track the progression of your son/daughter through school, college and
university and stay in touch. This might include invitations to events, good luck cards and short
questionnaires.
If you do NOT wish your son’s/daughter’s contact details to be retained for this purpose, please tick 
Responsibilities
Whilst we will take care of all our students’ welfare at all times, all On Track to Bath students will be treated as
responsible adults. Therefore, whilst travelling to and from events and whilst on campus but not participating
in an On Track to Bath event or activity, all participants are responsible for themselves and their behaviour.
If you have any questions about this please contact Samuel Wenman using the contact details on the first
page of the form.
Declaration to be signed by Parent/Carer
I have checked the information on this form and, to the best of my knowledge, it is true and correct.

I have read and understood the information above and I give permission for my son/daughter to attend the
On Track to Bath programme.

Thank you. Please sign below and return this form to your son/daughter
Signature of first Parent/Carer:__________________________________________________________
Date:______________________
Signature of second Parent/Carer:________________________________________________________
Date:______________________
SECTION 3: TEACHER’S RECOMMENDATION
Please give reasons why you think this student would benefit from participating in the On Track to Bath programme:
Is this students in receipt of a Post 16 Bursary or has been in receipt of Free School Meal?
Yes

No

Please give details:
Is this student part of any school programme such as Gifted and Talented, Advanced graduates?
Yes

No

If yes please give details:
Has this student experienced difficult family or individual circumstances that may have affected their
performance in exams or the likelihood of their going to university?
Yes

Please give details:
Signature of teacher __________________________________
Date _______________________________
No
