British History Summer School 2014 - Student registration document

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The Centre for Global Programmes looks forward to welcoming you to the University of York and thanks you in advance for providing the following information.

** Please note that in addition to completing this form, a short reference and recommendation from a member of academic or support staff at your university and copy of your passport should be sent to cgp-summerschools@york.ac.uk**

Personal details

Title *

Forenames/Given names *

Surname/Family name *

Date of birth *

YYYY

Address *

Telephone number (for emergency use) *

Your mobile phone number *

Email address *

Gender *

Male

Female

Accommodation

Do you require University of York accommodation? *

Yes

Educational information

Which University are you from? *

What is your main subject at University? *

What academic year are you in? *

1st, 2nd, 3rd etc

Health

Do you have any special dietary requirements? *

If yes, please give details: e.g. vegetarian

Are there any special requirements that we should know about when allocating accommodation? *

If yes, please give details: e.g. mobility

Do you have any allergies or other medical problems? *

If yes, please give details

Will you need to take any medication during your stay in York? *

If yes, please give details

Are you allergic to any medication? *

If yes, please give details

Passport details

Please email a scanned copy of the personal details page of your passport to cgp-summerschools@york.ac.uk

Nationality *

Country of origin *

Passport number *

Name on passport *

Place of issue *

Issue date

YYYY

Expiry date

YYYY

Place of birth *

Mother tongue *

Declaration

Please select the following option as appropriate *

I GIVE permission for the Centre for Global Programmes to use my photograph, video image and sound recordings in online and printed promotional material for the University of York. I waive all rights I may have in respect of these images and recordings

I DO NOT GIVE permission for the Centre for Global Programmes to use my photograph, video image and sound recordings in online and printed promotional material for the University of York.

Signature *

By typing your name below, you ACCEPT that records relating to your registration attendance and achievement at the Centre for Global Programmes will be kept on paper and on computer in accordance with the Data Protection Act 1998. As you are completing this form electronically, typing your name below will serve as a signature.

Today's date *

YYYY

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