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Application+Form+(MS+Word)

Application+Form+(MS+Word)

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Published by: Novi Assirotun Batutah on Mar 06, 2013
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International
Summer School 2012
Application Form
Personal Details
First NameSurnameKnown asGendeDate of BirthAge at 1 July, 2012Nationality
[Minimum accepted age at 1 July is 18]
Postal AddressLine 1Line 2CityCountry Postal/Zip CodePhone Number (including country code)Email AddressHow did you hear about the University of East Anglia’s International Summer School?Home Institution UEA Website BrochureStudy Abroad/HE Fair Flyer PosteOther 
Educational Details
Current/most recent home institutionCountry of home institution Degree Major Current level and year of study
(e.g. undergraduate 2
nd
year)
Highest qualificationachieved:
UEA International Summer School 2012 Application 1
To apply, please complete this application form electronically and return it by email or print to complete and returnit by post/fax. In either format the application form must be submitted with the following:
An academic referee who is a member of staff at your current or recent college or university
Passport photo (one digital if emailed, or two printed if posted)
Proof of current Grade Point Average (GPA/academic transcript)
Proof of IELTS score or equivalent English skill, if applicableUpon arrival, students must show their medical/travel insurance certificate and, if a national of a non-EEA country,a student visitor visa. The University can decline entrance to the programme without these.
 
Current Grade Point Average (GPA)Award Date Awarding Institution
 You will need to provide documentation to support this with your submitted Application.
Is English your first languageYesNo
If English is not your first language, please provide proof of English proficiency. Levelrequired is a minimum IELTS (or equivalent) score of 6.5.
Please contact us before submittingan application if you do not meet the minimum requirement specified.Qualification NameGrade ReceivedAward Date
 You will need to provide documentation to support this with your submitted Application.Academic referee
First NameSurnameInstitutionRelationship to RefereePostal AddressLine 1Line 2City Country Postal/Zip CodePhone Number (including country code)Email Address
Please ensure that your referee is willing to be contacted by the University should we needto verify your GPA or any other eligibility criteria.
Module Selection
Students will complete ONE 20 credit module during the International Summer School.
Our webpages will provide up to date information on availability. It may be possible to change preferences, subject toavailability, after submitting an application. Places will be allocated on a first come first served basis with a deposit paid tosecure choice(s) made. We recommend specifying a second and third option to secure a place on the Summer School.
Please clearly specify module title as displayed at: www.uea.ac.uk/summerstudyabroad/modules
 
First module choiceSecond module choiceThird module choice
Module Supplement
Students selecting
Spirituality and Identity in the UK
OR
Contemporary British Theatre
will berequired to pay a supplement of £495 to cover London accommodation and excursions.
Please tick to secure London accommodation/academic trips:
London Supplement (£495)
Details of the London accommodation, academic trips and social programme in London are on our webpages. Thesupplement will be due with the programme fee balance by 31
 
May. The University reserves the right to withdraw theLondon element of the programme for the specified modules and relating supplement paid would be reimbursed in full.
UEA International Summer School 2012 Application 2
 
Disabilities/Additional Requirements
The University welcomes students with disabilities and strongly encourages you to disclose any disability or medicalcondition which may impact upon your studies. This will not affect the academic decision about your application but willhelp us put any individual arrangements or facilities in place for the start of your study abroad programme with us.
Please tick all that apply:
No known disabilitiesUnseen disabilities e.g. diabetes Blind/partially sightedMental health difficultiesWheel chair user/Accessibility difficultyDeaf/hearing impairmentLearning difficultiesAutistic spectrum disorder/AspergersOther 
Please provide details of anyadditional support you mayrequire:
Equal Opportunities
The University aims to create an environment for learning that is tolerant and respectful, providing equal opportunities for all. To assist with our monitoring please indicate your ethnic origin. This information will not be considered as part of theapplication process.
White
IrishBritish Other White background
Black/Black British
 AfricanCaribbean Other Black background
 Asian/Asian British
IndianPakistan Bangladeshi Other Asian background
Mixed
White and
 
Black Caribbean White and Black AfricanWhite and Asian Other mixed background
Chinese Other ethnic group
Additional Social Programme
The basic fee includes at least one weekday and one weekend activity each week.
We’ve developed an excitingadditional social programme bundle to give you a GREAT discount for a fun filled 4 weeks’ social activities!
For activity details and pricing structures please read the Pricing Guide on our Social Programme webpages. A £100 depositis required to secure the additional social programme advance price and this will be deducted from the balance due.
Please tick one option:
No Additional Social Package
(at time of booking)
Package A (£180) Package B (£775)Package L (£140)Package W1 (£385)Package W2 (£385)Package W3 (£385)Deposit Due£100Total Amount for Social Package
(inclusive of deposit)Full payment will be due with the programme fee balance by 31
 
May. The University reserves the right to amend the datesof individual trips and in the event of a trip not running, an equivalent activity will be provided.
Full Board Catering
We’ve secured a GREAT deal with the University’s catering service so you can dine in our restaurant up to threetimes a day throughout your stay for less than £13.00 per day!
This includes a full continental breakfast, a two courselunch and a 2 course dinner with selected drinks. For full options please visit our Fees webpages. The catering bundle canonly be purchased in advance, requires a £100 deposit and must be paid for in full by the final fee deadline on 31 May.
Please tick one option:
No Full Board Catering
(at time of booking)
Package A 335) Deposit Due£100
UEA International Summer School 2012 Application 3

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