Apply for 2019 Programme

Register with us by filling out the form below.

RM_Stats

Section 1: Applicant Details

First Name ^*

Last Name ^*

Secondary School ^*

Email ^*

Year in school as of 1 April 2019 ^*

Select an optionYear 11Year 12

Home address ^*

Town/City ^*

Mobile Number ^*

Date Of Birth ^*

Ethnicity ^*

Section 2: Emergency contact details

Full name ^*

Relationship to you ^*

Address ^*

Daytime contact number ^*

After hours contact number ^*

Email

Section 3: Personal essay

Personal essay ^*

Section 4: Programme information

First choice for programme dates ^*

Select an option7-12 July14-19 July

If your first choice is not available, would you like to be considered for the other programme dates? ^*

• Yes
• No

Are you able to bring a smartphone or cellular connected tablet? ^*

• Yes
• No

Known health conditions ^*

Current medications ^*

Dietary requirements (medical or religious requirements only please)

• vegetarian
• vegan
• dairy-free
• gluten-free
• Other

Teacher reference

Name of teacher submitting reference on your behalf ^*

Teacher's email ^*

Terms and Declaration

I Agree

I declare that, to the best of my knowledge the information provided by me is true and correct.