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Middlesex University
Summer School Application Form
This form is to be used for Summer School applications only * fields are mandatory
Admin Staff (for Office use only): ______________________________________________________________
Personal details (As they appear on your passport/driver's licence or other official ID)
Family name:
First name(s):
Previous name:
Gender
Male
Date of Birth: (DD/MM/YY)
Female
Title: (Mr/Ms/Miss/ etc)
Correspondence address:
Postcode/zip code:
Country
Tel No:
Mobile
E-mail:
Academic details Applicants for credit bearing courses only:
If you are currently a student at a university or college other than Middlesex University please complete the following
section:
Name of Partner Institution
Baylor University
Birmingham-Southern College
CAMPUS 02
CUNY, College of Staten Island
Fulton-Montgomery Community College
Iowa State University
Northeast Community College
Plymouth State University
University of Northern Colorado
CUNY Baruch College
Towson University
University of St Josephs Macau
SUNY Brockport
SUNY Purchase
SUNY, New Paltz
Other
If selected other above (Please specify)
Name of Sponsor or Company:
Programme title:
Do you wish to undertake assessment for academic credit?
Yes
No
Do you require summer school credits to count towards your degree?
Yes
No
Courses applied for
Title 1
Course Code:
Title 2
Course Code:
Alternative course:
Title 1
Course Code:
Title 2
Course Code:
Summer Package
Students from partner institutions please indicate whether
you will be joining our 3 or 5 week package
3 week Package
5 week Package
Please note that tuition, accommodation and social and cultural programme are included in the package.
If you are not from a partner institution but would like to join one of our summer packages please tick one of the
above
Highest qualification
Please detail the highest level of education completed e.g. GCSE, A' Level, Diploma, BA, MA etc
Qualification Type:
Name of institution and country:
English language qualifications
Please note that students who are studying courses other than English Language courses are required to have IETLS 6.0 or
the equivalent if English is not their first language.
Qualification Name:
Grade Achieved:
Award Date
Disabilities or special needs
The University encourages you to disclose any disability/medical condition which could disadvantage your ability to study.
The information you submit will be used to help Middlesex University provide appropriate support and will not affect your
application. Please choose all that apply.
This is a mandatory section
No disability (0)
Dyslexia (1)
Blind/partially sighted (2)
Deaf/hearing impairment (3)
Wheelchair user/mobility issues (4)
Personal care support (5)
Mental health difficulties (6)
Unseen disability: e.g. Diabetes (7)
Autistic Spectrum/ Asperger's (T)
Other
If your disability is not mentioned above and you
have ticked other then please specify:
Please mention any other additional support needs
(if required):
Accommodation
Accommodation is included in our summer packages. If you are not joining one of these, you will receive information about
accommodation options separately.
Fee Payment
Please provide details of how your fees will be paid:
Baylor University
Birmingham-Southern College
CAMPUS 02
CUNY, College of Staten Island
Fulton-Montgomery Community College
Iowa State University
Northeast Community College
Plymouth State University
University of Northern Colorado
CUNY Baruch College
Towson University
University of St Josephs Macau
SUNY Brockport
SUNY Purchase
SUNY, New Paltz
Other
If you ticked Sponsor or Employer above then please specify the name:
Country of permanent residence:
Country of Birth:
Nationality (as on Passport)
Have you ever lived outside the UK/EU?
Yes
No
Yes
No
If yes, Where:
Have you entered the UK on a Visa?
Last date of entry to the UK/EU:
Please note that successful applicants will only be issued an unconditional offer letter, required for some Visas, once full
payment has been received
Please state below how you heard about Summer School:
Achievement Officer
Communications
Direct mailing - Email
EU Portals
Floodlight
Google Search
Hot Courses
Middlesex University Admission
Middlesex University Alumni Website
Middlesex University Lecturer
Middlesex University Regional Office
Newsletter
Previous Summer School Student
Study abroad office
Study abroad Fair
Summer School Website
UNIHUB
Other
If you ticked other above then please specify below:
Ethnic origin and equal opportunities monitoring
The University is committed to providing equal opportunities for all. To assist us with our monitoring please choose one of
the boxes below.
This form will be separated from your application and the information supplied will be recorded on our computer system
for statistical monitoring purposes. This information will not be considered as part of the admissions process.
This is a mandatory section
British (11)
Caribbean (21)
Indian (31)
Irish (12)
African (22)
Pakistani (32)
Scottish (13)
Other Black Background (29)
Bangladeshi (33)
Welsh (14)
White & Black Caribbean (41)
Other Asian Background (39)
Other White Background (19)
White & Black African (42)
White & Asian (43)
Chinese (34)
Other Mixed Background (49)
Not Known (90)
Information Refused (98)
Declaration of criminal record
In an effort to help the University reduce the risk of harm or injury to their staff and students caused by the criminal behaviour of other students
we must know about any relevant criminal convictions an applicant has.
In this matter relevant criminal convictions are deemed only to be those convictions for offences against a person, whether of a violent or sexual
nature and convictions for offences involving unlawfully supplying controlled drugs or substances where the conviction concerns commercial
drug dealing or trafficking.
Convictions that are spent, (as defined by the Rehabilitation of Offenders Act 1974) are not considered to be relevant and you should not reveal
them, unless you are required to complete an ‘Enhanced Disclosure Document’ from the Criminal Records Bureau or the Scottish
Do you have a relevant unspent criminal conviction?
Yes
No
If you have ticked Yes, please disclose details of your offence and conviction, including dates and courts convicted at. This information should be
submitted along with your application form in a separate sealed envelope, clearly marked confidential with your name and date of birth on it. If
you will be sending this form via email then alternatively you can send us a word file along with your application via email and can be sent
directly to [email protected] clearly marked confidential with your name and date of birth in the email header.
Any information disclosed will be handled and disposed of securely by Middlesex University in compliance with the Criminal Records Bureau
Code of Practice, the Data Protection Act and other relevant legislation.
If you are convicted of a relevant criminal offence after your application has been submitted, you must notify us. The university may request
further disclosure from you and your offence may affect your application.
Declaration
I confirm that the information given in this form is true, complete and accurate: no information requested or other material information has been
omitted. I consent to the processing of this data by Middlesex University for educational purposes under the provision of the 1998 Data
Protection Act.
I understand that if studying a course with an exam assessment element it is my responsibility to be available to attend on 3 August 2015.
I understand that Middlesex University reserves the right to cancel or amend Summer School courses for reasons of viability or due to any other
unforeseen circumstances, in which case any fees paid will be refunded in full.
Please tick to confirm that you have read the above
declaration
*
Signature/Name:
Date (DD/MM/YY):
If you are not applying through a partner institution, please scan or post this completed form to:
Summer School Office, Middlesex University, The Burroughs, London, NW4 4BT, United Kingdom
Tel: +44 (0)20 8411 5782
Email: [email protected]
Web: www.mdx.ac.uk/summer