Enrolment Form

Course Title:

Personal Details
Title: M/F: First name: Nationality: Last name: Date of Birth:

Address:

Telephone (day): Email Address:

Other Information The UK government agency HESA uses some of the information on this form for statistical analysis as a condition of funding for the University. HESA is registered under the Data Protection Act. The personal information you give will not affect your application, and will only be sent to HESA if your application is successful.
Occupation: Do you have a disability / special need? If so, please state your disability: Please describe any special need/support required to assist you with your study Yes No Retired: Yes No

(e.g. disabled access, Hearing Loop etc. Weask this so we can assist you where possible)

How would you describe your Ethnic origin? (tick one box) Bangladeshi Chinese Black African Indian Black Caribbean Pakistani White Black Other Other Asian Irish Traveller

Mixed White/Black Caribbean Mixed White/Asian Other ethnic background

Mixed White/Black African Prefer not to say

Other Mixed

How did you hear about this course?

Qualifications
Formal education achieved (Please tick all relevant boxes) GCSE/O levels/School Certificate First Degree: (P/G Cert/Dip) (UK) (EU) (UK) (Masters) (other) (EU) (other) Postgraduate Certificate in Education (P/G Level) (PhD/DPhil) Postgraduate Degree: A Levels/Higher School Certificate

Undergraduate Certificate in Education Professional Qualification: (U/G Level) Other (please state):

Where did you first hear about our website?

In print: An advert in a newspaper or magazine. Which magazine? The Continuing Education Newspaper The Continuing Education Annual Prospectus

Online:
The Oxford University Continuing Education website A search engine Linked from another website.

Which website?

Via email from: Continuing Education

Other. Who sent it?

On a leaflet, flier, brochure, or postcard found in: A library or museum Continuing Education premises A direct mailing A magazine Other. Please specify: Other: Friend / recommendation / referral Conference / Event / Open Day Other. Please specify:

The Department for Continuing Education may occasionally wish to collect images (both photographs and video recordings) of its activities, including lectures, tutorials, seminars and social events. These photographs and video recordings may be used by the Department for Continuing Education and the University for the promotion of their educational activities. I hereby grant to the Department for Continuing Education and Oxford University the right and permission to take, hold, use, and publish photographs and video recordings in which I appear in printed or electronic media, including the internet, for advertising and promoting educational activities. I understand that if I no longer want a photograph in which I appear to be used, I can contact onlinecourses@conted.ox.ac.uk to request that it be removed. However, I accept that it might not always be possible to remove all existing copies from circulation. Please tick this box if you do not wish photographs and video recordings of you to be used as described above. Information collected on this form will be held in accordance with the provisions of the Data Protection Act 1998 for the purposes of processing your application and for student administration. It will be held securely and not passed on to third parties (please see our privacy policy for further information). Periodically, the Department may send you information about its future programmes, about other activities related to its programmes and about the benefits and services which are available to students of the Department. If you do not wish to receive such information, please tick the following boxes: I do not wish to receive information by post I do not wish to receive information by e-mail

I hereby undertake to abide by Departmental and course regulations

(copies available on request)

Signature:

Date: dd-mm-yyyy

Payment
1. I enclose the fee of: (cheques payable to OUDCE) 2. Please charge my Mastercard/VISA/Switch account with the sum of: Mastercard/VISA/Switch account number: Card Expiry Date: Card security number: Signature: Date: dd-mm-yyyy Switch Issue Number:

Please fax this enrolment form to 01865 280975 or post with payment to: Online Courses, Ewert House, Ewert Place, Oxford OX2 7DD.

Print Form