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student enrolment form

Easter Courses: Monday-Thursday 6th – 9th April 2009

Personal Details
First name: ................................................................ Surname: ..................................................................
Date of birth: ...................................... Age................... Gender: Male  Female 
Address: ...................................................................................................................................................
...............................................................................................................................Postcode:..............................
Home tel:............................................ Mobile:............................................ E-mail:..........................................
Emergency contact: .........................................................................................................................
Emergency contact number: .........................................................................................................................
Relationship to student: .........................................................................................................................
Do you have any access needs; disabilities or medical conditions we should be aware of? Yes No
Please give details: …...........................................................................................................................................
Course Selection
Bishop Challoner George Green Central Foundation
Hair & Beauty  Cookery & Food Hygiene  Music Production 
Drama  Digital Photography &  Cake Baking 
Photoshop
Cookery  Mountain Biking  Street Fashion 
The Young Apprentice  Trampoline  Urban Adventure 
First Aid  Badminton  Sports Mentoring 
Street Dance  Street Dance  Bike Ability 
First Aid 
Current Education
GCSE  A Levels  BTEC  NVQ  Training 
Not in education  Other  .....................................................
Name of school/college:.........................................................................................................................

Cultural Origin
Black African  Indian  Asian UK  White other 
Black Caribbean  Pakistani  Asian other  Other 
Black UK  Bangladeshi  White UK  ..............................
Black other  Chinese  White European 

Image Permission
Summer Uni will document its activities through film and photography. Images and films may be used to
evaluate and promote our activities in marketing/publicity materials, on our websites and in funder
reports. If you would prefer not to be included in such materials, please tick the box 

Signed: .................................................................................................................... Date:...................................


(Parent or carer to sign/consent if the participant is under 16)

You must now return the completed form to the contact person in your school who will forward it to us.
Alternatively, please send it to: Joanne Whalley, Project Officer
Tower Hamlets Summer University, Ground Floor, 24-26 Fournier Street, London E1 6QE

We will call you by Friday 3rd April 2009 to let you know if you have been successful in getting onto your selected
course. Limited spaces available – first come, first served.

Tel: 020 7247 7900 E-mail: joanne.whalley@summeruni.org Fax: 020 7377 9793 Web: www.summeruni.org

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