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LONDON SCHOOL OF HYGIENE & TROPICAL MEDICINE

REGISTRATION FORM - ACADEMIC SESSION 2010-11


The names recorded are those which will be given on all official documents issued by the School and the University of London and must be given on your previous qualifications. These cannot be changed without documentary evidence being provided to the Registry.

PERSONAL DETAILS - PLEASE CHECK AND AMEND AS APPROPRIATE


Course: Family Name: Other Names: Gender: Nationality: Disability: Have you ever started a higher education course (i.e. above A level or equivalent) in the UK before? If yes, did you attend this course for 6 months or more? MSc - Control of Infectious Diseases VANHOVE MATHIEU CHRISTOPHE Male France Date of Birth: Ethnic Origin: 10 January 1988 White

Student No: Full-time/Part-time: Title:

271529 Full-time MR

YES/NO YES/NO

(Please delete as appropriate) (Please delete as appropriate)

ADDRESS DETAILS - PLEASE CHECK AND AMEND AS APPROPRIATE


(You are required to inform Registry of any change in your permanent or London Term-time address). TERM-TIME ADDRESS: PERMANENT HOME ADDRESS (overseas address for students from abroad): 2 ALLEE DE LA REINE GUENIEVRE 35830 BETTON FRANCE

2 ALLEE DE LA REINE GUENIEVRE 35830 BETTON FRANCE

Postcode: Telephone: Mobile: 0033 2 99 55 15 41 07 55 27 06 295

Postcode: Telephone: e-mail: 0033 2 99 55 15 41 m.vanhove@sms.ed.ac.uk

Type of accommodation: School/University residence; Your parent's home; Your own home / rented accommodation Other

EMERGENCY CONTACT DETAILS - PLEASE COMPLETE IN BLOCK CAPITALS


Person to be contacted, either in the UK or overseas, in the event of accident or other emergency: Name: Address:

Telephone number: Relationship of this person to you (for example, Father/Wife):

ALL STUDENTS SIGN BELOW


I confirm that the information given on this form is correct and that I have read and accept the Regulations Declaration SIGNATURE DATE

DECLARATION [TO BE READ PRIOR TO SIGNING THE REGISTRATION FORM]


Student Regulations I agree to observe the Masters and Diploma Regulations and the Examinations Procedure; the Regulations for the degrees of MPhil, PhD and DrPH; the Withdrawal and Appeal Procedure; the Regulations for use of Networked Computing Services; the Library Rules and the Freedom of Speech Code of Practice. I understand that any infringement of Codes of Practice or the regulations will render me liable to disciplinary action by the School. Copies of the above documents are available for inspection on the School intranet or from the registry Attendance I understand that a course of study must be continuously pursued. Any interruption in attendance during the period of registration through illness or other exceptional cause lasting more than seven days must be notified in writing to the Head of Registry Services and, where relevant, a medical certificate produced. Tuition Fees I understand that my tuition fees are payable in full by the end of the first week of the course of study. I undertake to keep the Head of Registry Services informed in writing of any financial difficulty which may affect my ability to pay any fees or charges which become due during my course. I understand that the School is normally unable to assist with any financial difficulties which arise during the course. I understand that appeals against fee status decisions will not be considered more than one calendar month after the start date of my course. Disclosure of Personal Information I understand that my personal details held by the School will normally be regarded as strictly confidential to the officers and authorised agents of the School but in the event of accident, illness or other urgent cause I authorise the Head of Registry Services to disclose such information as he may consider appropriate. I consent to the transfer of my assignments and any other submitted material to Turnitin UK to be crosschecked for the purpose of identifying plagiarism. I agree to the transfer of the necessary personal data to accomplish this task. I understand that Turntin UK will at all times abide by the Data Protection Act 1998 in regard of my personal data. I consent to my photograph being used for the production of class photolists and similar lists within the School. I consent to my name and contact details to be passed to the Careers Group, University of London in order to assist with any careers advice I may with to receive. Copyright I understand that the copyright of any coursework, project, dissertation or thesis produced by me vests with me as the author and that no copying, issuing or publication of such works can occur without my prior written consent. I authorise that any coursework, project, dissertation or thesis presented by me for examination for a degree of the University of London may be deposited in the library of the London School of Hygiene Tropical Medicine, and that, subject to the conditions set out below may be made available, either in print or electronically, for public reference, interlibrary loan and copying. I authorise the School Library and their designated agents to make a photocopy or digital copy of any such work for the purposes of inter-library loan and the supply of copies to library users and members of the public. I authorise the School to make a microform or digital copy of this work as the archival copy for permanent retention in substitution for the original copy. I authorise library users to copy up to 5% of the work for their own personal research for a non-commercial purpose or for private study. [A candidate may apply to the School for restriction of access, for a period not exceeding two years, to an MSc project, DrPH Organisational and Policy Analysis Project report or DrPH/MPhil/PhD thesis on the grounds of commercial exploitation, patenting or in very exceptional circumstances and in accordance with the procedure adopted by the School for consideration of such applications.] Security Pass I undertake to hold a security card for the School building access system and to abide by the regulations in respect of that system. I understand and accept that I will be charged a fee for any further replacement card. Criminal Offences [For medically-qualified students only] I declare that I have not been convicted by any court of any criminal offence and that I have not been suspended or disqualified or prohibited from practising medicine, or from being registered as a medical practitioner, in any country. If this position should change while I am a registered student I undertake to inform the Head of Registry Services in writing within twenty-one days of such a change taking Students' Representative Council The London School of Hygiene Tropical Medicine's Students' Representative Council (SRC) is a body representative of the generality of students at the School in academic, disciplinary and other matters. Under the provisions of the Education Act 1994 students have the right to signify that they do not wish to be represented by the SRC and if they wish to do so they should complete the following, recalling that if they do so they will not be entitled to vote in SRC elections unless they formally revoke this undertaking in writing. If you do not wish to be represented by the students' representative council please contact the Registry at registry@lshtm.ac.uk or on 020 7299 4648 University of London Union (ULU Students at constituent colleges of the University of London are entitled to representation, support and services from the University of London Union. In order to facilitate this, the School will provide ULU with your name, enrolment number, course title and School email address. If you would prefer the School to withhold these details from ULU, please contact the Registry at registry@lshtm.ac.uk. Students who choose to withhold these details will not be entitled to vote in ULU elections unless they formally revoke this undertaking in writing. HESA (Higher Education Statistics Agency) We are required to send some of the information we hold about you to the Higher Education Statistics Agency (HESA). This forms your HESA record, which contains details of your ethnic group and any disabilities you have. For further information please refer to the HESA Fair Processing Notice at http://intra.lshtm.ac.uk/registry/regulations/studregs_other.htm