SELECT COURSE

APPLICANT'S DETAILS

Surname:
First name:
Gender:	Male Female
School Year:
Date of Birth:
Nationality:
Mobile Phone:
Email:
Telephone (daytime):
Telephone (evening):
Address line 1:
Address line 2:
Town:
County:
Postcode:
The Smallpeice Trust is committed to a policy of equal opportunities. Please complete this section for monitoring purposes only. I am:
White – British 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 Asian or Asian British – Bangladeshi Chinese or other Ethnic Background – Chinese Other Asian Background Mixed – White and Black Caribbean Mixed – White and Black African Mixed – White and Asian Other Mixed Background Other Ethnic Background
What is the single most important factor which influenced you to apply for this course?
A friend/family member Visit from Smallpeice Trust At a careers fair My school/teacher Smallpeice mailing/e-shot Our website Other website - please specify* Other - please specify*
*
What has attracted you to apply for this course? (mention any involvement with engineering related clubs, subjects studied at school, career aspirations, hobbies and interests etc)
If accepted onto the course, what skills will you be able to offer your team members? (provide examples of times when you have applied these skills)
Have you ever attended a Smallpeice activity day (STEM) at your school?
YesNo

PARENT(S) / GUARDIAN DETAILS AND AUTHORISATION

Title:	Mr & Mrs Mrs Mr Ms Miss Dr
First Name:
Surname:
Telephone:
Address line 1:
Address line 2:
Town:
County:
Postcode:

PARENT(S) / GUARDIANS AGREE: yes no

Please check the box to confirm that the applicant's parent(s) / guardian(s) give permission for the applicant to attend the indicated Smallpeice Trust residential course. They understand that if the applicant's application is successful, they will be responsible for arranging transportation to and from the course venue. They understand that students may have to cross a main road between the residential accommodation and working rooms, and that it may not be possible to put male and female students into separate blocks, but at a minimum the genders will be segregated by floor. They have read the conditions below and fully understand them.

SCHOOL AND TEACHER DETAILS

Title:	Mr Mrs Ms Miss Dr
First Name:
Surname:
Please enter your position:
School Name:
Address line 1:
Address line 2:
Town:
County:
Postcode:
Telephone:
Email:

INVOICING - A successful application will incur a non-refundable registration fee. An invoice will be forwarded to the parent/guardian unless a different name and address is entered here.

CONDITIONS - Registration fees are to be paid within two weeks of the date of invoice. The Smallpeice Trust reserves the right to withdraw student’s places where the invoice is unpaid. Notification of withdrawal of a place will be made in writing. Course fees are non-refundable and we reserve the right to charge non-attendance at the full unsubsidised rate where less than 10 days notice is given. As the payee of the registration fee, I understand these conditions. 

= Required