Booking Form Phone Student Details Student's First Name Student's Surname Student’s Date of birth Student’s Gender Male Female Other Student’s Age (at time of course) Student’s Nationality Student’s Mobile Student’s Email Student’s Current School Parent/Guardian Details First Name * Home Phone Number * Last Name * Mobile phone number * Address line 1 * Address line 2 Address line 3 Town/City * County * Postcode * Country * Emergency Contact Please provide an additional emergency contact for the student that is different from the parent/guardian details already given above. Ideally this person would reside in the UK at the time of the course in case of an emergency. Full Name of the Emergency Contact * How is this person related to the student? * Mobile Number of the Emergency Contact * Student Qualification Level Student Qualification Level GCSE IGCSE A-level Subjects Students can take up to 3 subjects for each week of study. Please list the subjects you would like to revise during your time with us. Please take care when listing the course code; it is essential that this is correct so that we can ensure that appropriate tuition is provided. If your subject is not listed, please request it in the space provided. Subject 1 Biology Business Chemistry Classics Drama and Theatre Studies Economics English Literature English Language EPQ French General Studies Geography German Government and Politics History History of Art Law Mathematics Philosophy Physics Politics Psychology Religious Studies Sociology Spanish ==GCSE SUBJECTS== Art and Design Biology Business Chemistry Classics Combined Science Economics English Language English Literature French Geography German Government and Politics History Humanities ICT Law Mathematics Physics Politics Psychology Religious Studies Science Spanish Exam specification Course code Predicted grade (if known) Subject 2 Biology Business Chemistry Classics Drama and Theatre Studies Economics English Literature English Language EPQ French General Studies Geography German Government and Politics History History of Art Law Mathematics Philosophy Physics Politics Psychology Religious Studies Sociology Spanish ==GCSE SUBJECTS== Art and Design Biology Business Chemistry Classics Combined Science Economics English Language English Literature French Geography German Government and Politics History Humanities ICT Law Mathematics Physics Politics Psychology Religious Studies Science Spanish Exam specification Course code Predicted grade (if known) Subject 3 Biology Business Chemistry Classics Drama and Theatre Studies Economics English Literature English Language EPQ French General Studies Geography German Government and Politics History History of Art Law Mathematics Philosophy Physics Politics Psychology Religious Studies Sociology Spanish ==GCSE SUBJECTS== Art and Design Biology Business Chemistry Classics Combined Science Economics English Language English Literature French Geography German Government and Politics History Humanities ICT Law Mathematics Physics Politics Psychology Religious Studies Science Spanish Exam specification Course code Predicted grade (if known) Other subjects: Which units (if any) have you already completed? If known, which grades did you achieve? What are your main areas of weakness in this subject (exam technique, subject knowledge, revision technique etc)? Which topic/unit would you most like to cover in this course? Any other comments: Course Dates Please indicate which week(s) you would like to book. May Half Term Week 1: 27th - 31st May Summer Holidays Week 1: 8th – 12th July Week 2: 15th – 19th July Week 3: 22nd – 26th July Week 4: 29th July – 2nd August Week 5: 5th – 9th August Week 6: 12th – 16th August Week 7: 19th – 23rd August Christmas Holidays Week 1: 9th – 13th December Week 2: 16th – 20th December Payment Details Upon receipt of your booking form an invoice will be sent with the details of how to pay and the full payment amount required. Accommodation Please indicate whether you would like to book residential (full-board) or non-residential (including lunch). Accommodation Residential Non-residential Dietary Requirements If the student has any specific dietary requirements, please describe them here. We cater to most dietary requirements. Dietary Requirements Educational Needs Please also give details of any educational needs, such as dyslexia, or any other information that may affect the student's learning. Educational Needs Medical Conditions and Allergies Please provide information about any medical conditions or allergies that may affect the student whilst on the course. This information is particularly important in case of an emergency. Medical Conditions and Allergies Where did you hear about us? Fitzwilliam Academics requires all students to participate in the scheduled activities and offsite trips advertised in the Fitzwilliam Academics brochure. All activities are undertaken at the participant’s own risk. Please tick the box to confirm that you give permission for your son/daughter to participate and that all relevant medical conditions have been disclosed above. Offsite Trips Consent I agree Fitzwilliam Academics will use your personal data to make your booking and contact you with further details on the programme. Further information on how we use your data can be found in our privacy policy and data protection policy. Please tick this box to confirm that you have read this information and accept these policies. Personal Data Consent I agree From time to time, Fitzwilliam Academics would like to send you offers and information you might be interested in. If you would like to receive this information, please tick this box. Offers and Information Consent I agree
