Registration Form for Tutor/Mentor

1. Personal Information
Name:

Date of Birth:

Joseph Jiah-Jieh Liao

11/12/1993

2. Contact Information:
Term time address
34 Coniston House, Maplin St, Mile End, London, E3 4SU
Email:

Phone / Mobile:

j.j.liao@se12.qmul.ac.uk

07424533213

3. University and Course Details

University: Queen Mary University of London
Course Title: BEng Aerospace Engineering
Year of course:

Full time / Part time

Full Time

Course Start Date:

Course End Date:

September 2012

June 2017

4. Please state your disability below.

Please note the above is optional, leave blank if you prefer not to say.

5. Please indicate below your available times to meet with a tutor/mentor:

Please select as many available time periods to enable us to best match you with your
support worker.

Mon
Morning

Tues

Wed

Thurs

Fri

Sat

X
X

Afternoon
Evening

X
X

6. Please state where you would like the support to take place.
Bloomsbury

Stratford

Docklands

Queen Mary
X

7. Please include your funding details below and confirmation of your funding from your
funding body:
Funding Body (i.e. SFE):

Hours allocated:
Per Year
(delete as appropriate)

Customer Reference Number:

Information on this registration form will be used to match the client with a
tutor/mentor. Data will be stored on our student database and the form will
also be passed to your tutor/mentor. Following the matching process the
Client will be emailed a copy of the Client Terms of Agreement and the
Failure to Cancel Policy which will be deemed to have been accepted by
the Client unless otherwise stated.