Northern Ireland Residential
17-19 June 2015
Thank you for your interest in the Liverpool John Moores University Summer
Residential 2015.
This year, we are pleased to offer 50 places to Northern Irish students interested in
applying to LJMU. The Residential is funded by the University and is completely free
for participants.
It is a 3-day 2-night event which will allow you to find out more about the University,
your chosen course or subject area, and the city of Liverpool. We will meet at Belfast
City Airport at 8.30am on Wednesday, 17 June 2015 and we’ll fly to Liverpool
together. We will return to Belfast City at 20.45 on Friday 18 June 2015. The
programme will consist of workshops, talks and taster sessions as well as social
activities giving you a flavour of student life. You will be staying in the International Inn
close to the University and you will have plenty of opportunities to talk to our current
students, tour LJMU facilities, participate in the Open Day and explore the city.
Please use this form to tell us as much as you can about yourself and your reasons for
considering LJMU. We will allocate places available based on your supporting
statement and the reference provided by your teacher.
Completed applications can be returned to us via email, fax or post by 20 March 2015.
We will inform all applicants whether we are able to offer you a place via email by 2nd
April 2015.
Good luck!
The LJMU Outreach Team
Liverpool John Moores University, Student Recruitment & Widening Access, Kingsway House,
Hatton Garden, Liverpool L3 2AJ
Tel: 0151 904 6385; Fax: 0151 904 6368
Email: [email protected] Web: www.ljmu.ac.uk
Northern Ireland Residential
17-19 June 2015
STUDENT APPLICATION FORM
SECTION ONE – INFORMATION ABOUT YOURSELF (ALL FIELDS MUST BE COMPLETED)
FIRST NAME
LAST NAME
HOME ADDRESS
POSTCODE
HOME TELEPHONE NUMBER
MOBILE NUMBER (MUST PROVIDE)
EMAIL ADDRESS (MUST PROVIDE)
 Male
GENDER
 Female (Please tick box)
DATE OF BIRTH
PLEASE TICK THE BOX WHICH BEST DESCRIBES YOUR ETHNIC BACKGROUND:
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White - British
White – Irish / Northern 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
Other Asian background
Chinese
Mixed – White and Black Caribbean
Mixed – White and Black African
Mixed – White and Asian
Other Mixed background
Other Ethnic background
I prefer not to provide this information
PLEASE TICK ANY BOX WHICH DESCRIBES ANY ADDITIONAL NEEDS YOU MAY HAVE:
All additional needs should be disclosed on this form. This will not prevent you from taking part in the Residential. We need to
be aware of individual needs before you arrive in order to make sure that they are met.
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I need information about disabled access
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I have a visual impairment
_______________________________________
I don’t have any additional needs
I have a mobility difficulty
I use a wheelchair
I have a hearing impairment
I am dyslexic
I am dyspraxic
I have personal care support
Other – please give details
_______________________________________
I require adapted accommodation
_______________________________________
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PLEASE PROVIDE A STATEMENT TO SUPPORT YOUR APPLICATION. Approach this like you would approach your UCAS
application form! Tell us what qualifications and subjects are you currently studying for and what grades you are expecting
to achieve; which LJMU courses you are interested and why; tell us about any experience you may already have and why
you wish to take part in the event.
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SECTION TWO – TO BE COMPLETED BY PARENT OR CARER
Contact Telephone Number
Name and daytime telephone number of
parent/carer
Alternative Contact
Name and telephone numbers of another
adult if parent/carer unavailable
Special Requirements
Details of any special requirements
(e.g. diets, allergies, access needs, faith
requirements)
Further Information
Details of any other information that
University staff should be aware
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The student is living apart from family or in care of the local authority
PARENTAL BACKGROUND:
Mother/Carer
Father/Carer
OCCUPATION
HIGHEST QUALIFICATION
(please tick appropriate box)
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None
GCSE or O level
A level
HNC or HND
Degree or equivalent
Other (please state)
___________________
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None
GCSE or O level
A level
HNC or HND
Degree or equivalent
Other (please state)
___________________
DECLARATION – to be completed and signed by a parent or carer
The Residential team are responsible for the welfare of your son/daughter while they are attending the event. As
parents/carers, you are responsible for their welfare up to the handover point at the beginning of the programme,
and again from the handover point at the completion of the event. The team will contact you with details about
handover points and travel arrangements.
During the event, photographs/video footage may be taken which we may wish to use as a reminder of activities
or for publicity purposes to encourage other young people to take part in similar events.
Summer Universities target learners from communities under-represented in higher education. The information
provided in this form is used to allocate places and monitor applications.
By signing below I give permission for my son/daughter to attend the LJMU residential 2015 and for the
information provided in this form to be shared in order to allocate places and monitor applications.
SIGNATURE
PRINT NAME
DATE
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SECTION THREE - INFORMATION ABOUT YOUR SCHOOL OR COLLEGE - to be completed by school
NAME OF SCHOOL/COLLEGE
SCHOOL/COLLEGE ADDRESS
POSTCODE
TELEPHONE NUMBER
NAME OF STAFF MEMBER RESPONSIBLE
EMAIL ADDRESS
DECLARATION – to be signed by school/college
Please tick and sign below:
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I have checked the details on the application form and I confirm they are correct.
I give permission for the student to be absent from school/college during the NI Residential
Please use this space for any additional information about why you recommended the applicant for a place or
which would be useful for the event organisers to be aware of. We will rely on your reference as part of the
shortlisting process.
Information in this form is required to allocate NI residential places. Incomplete forms may not be processed.
SIGNATURE
PRINT NAME
DATE
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FOR OFFICE USE ONLY
DATE FORM RECEIVED
APPLICATION REF
COMMENTS
OFFERED PLACE
AUTHORISED BY
Data Protection
The information provided may be used to allocate places and monitor applications. Data may also be shared with the Higher
Education Funding Council for England (HEFCE) and for monitoring purposes to evaluate the effectiveness of this activity. HEFCE
will not use your record in a way that would affect you individually. Under the Data Protection Act 1998 you have the right to a
copy of the data held by us for a small fee. If you have any concerns about the use of data for these purposes or would like a copy
of the data you have supplied please contact the Residential team.
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