Summer work placement application About youName* First Last Date of birth* Age*Gender*MaleFemaleMobile number*Home numberEmail* Enter Email Confirm Email Home Address* Street Address Address Line 2 City Borough (London) or county (out of London) Postal Code Name of School*School Address* Street Address Address Line 2 City Borough (London) or county (out of London) Postal Code Is this school a grammar school?*YesNoIs this school a private school?*YesNoWhat is your ethnic origin?*Asian British – BangladeshiAsian British – IndianAsian British – PakistaniBlack British – AfricanBlack British – CaribbeanChinese or Other Ethnic background ChineseMixed – White and AsianMixed – White and Black AfricanMixed – White and Black CaribbeanOther Asian backgroundOther Black backgroundOther Ethnic backgroundOther Mixed backgroundPrefer not to sayWhiteWhite – BritishHave you ever received free school meals at high school or a bursary i.e education maintenance allowance?*YesNoDid either of your parents study at university in the UK and obtain a degree?*YesNoHave you ever been in care?*YesNoDo you have a disability?*YesNoAre you a member of any other higher education access scheme?*NoYesIf yes, please state which schemeHow did you hear about in2scienceUK?*in2scienceUK WebsiteTeacherParentScientistFuturesin2scienceUK school presentationSocial MediaPrimary subject choice*BiologyBiochemistryBiomedical SciencesChemistryChem EngEngineeringMech EngPhysicsPharmacyMedicineDentistryAstrophysicsComputer ScienceNeuroscienceMathematicsVeterinary ScienceVeterinary MedicinePharmacologyNatural SciencesGeneticsPsychologyOtherOtherSecondary subject choice*NoneBiologyBiochemistryBiomedical SciencesChemistryChem EngEngineeringMech EngPhysicsPharmacyMedicineDentistryPhysicsAstrophysicsComputer ScienceNeuroscienceMathematicsVeterinary ScienceVeterinary MedicinePharmacologyNatural SciencesGeneticsPsychologyOtherOtherPlease describe your reasons for selecting your choice of subject(s)*What do you hope to gain from an in2scienceUK placement?*Are they any dates during the summer holiday that you would be unable to attend an in2scienceUK placement?What grade did you get in your Maths GCSE?*n/aA*ABCDEWhat grade did you get in your English Language GCSE?*n/aA*ABCDEWhat grade did you get in your English literacy GCSE?*n/aA*ABCDEWhat grade did you get in your Core Science/Biology GCSE?*n/aA*ABCDEWhat grade did you get in your Additional Science/Chemistry GCSE?*Please select n/a if you did a single science GCSEn/aA*ABCDEWhat grade did you get in your Physics GCSE?*Please select n/a if you did a single/double science GCSEn/aA*ABCDEWhat A-levels are you studying?* Art History Geography Biology Chemistry Physics Maths IT Computer science English literacy English language A foreign Language Psychology Drama RE Other Please provide us with the name of a teacher at your school (usually your form tutor or head of Sixth Form). We ask this as we may contact them to provide us with a reference and to verify some of the information you have given us above.*What is the role of the teacher named above (e.g. science teacher, Head of Sixth Form, tutor).*Please provide your teacher’s email address (named above)*Terms & Conditions(Please tick the box below if you agree to this) I give permission for in2scienceUK to collect and store photographs of and/or audio visual material of me during the in2scienceUK placement. I understand that this material will be used to advertise and promote activities in the future, and that it will not be used for any other purposes. In your application to the in2scienceUK programme, you provided some information about your background and education. The data collected will be processed in accordance with the Data Protection Act 1998 and held for an extended period of time. If successful with your application, for research, monitoring and evaluation purposes only, your data may also be shared with appropriate third party organisations such as the Higher Education Funding Council for England, Higher Education Statistics Agency and our partners including Higher Education Access Tracker Service subscribers. This is to help us assess the impact and effectiveness of the in2scienceUK programme. We will not release data to anyone who is unauthorised. Under the Data Protection Act 1998 you have the right to a copy of the data held about you by us. By applying for the in2scienceUK programme, you are consenting to the use of your data as outlined above.