01 August 2022, English Summer School

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Title *

Mrs

Miss

Surname *

Name *

Date of Birth
(dd/mm/yyyyy) *

Gender *

Male

Female

Do you have any disability? *

Yes

Please, mention type of disability (if you have it)

No known disability

A specific learning difficulty such as dyslexia, dyspraxia or Attention deficit (hyperactivity) disorder

A social/communication impairment such as Asperger's syndrome/other autistic spectrum disorder

A long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, or epilepsy

A mental health condition, such as depression, schizophrenia or anxiety disorder

A physical impairment or mobility issues, such as difficulty using arms or using a wheelchair or crutches

Deaf or a serious hearing impairment

Blind or a serious visual impairment uncorrected by glasses

A disability, impairment or medical condition that is not listed above

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Home address (house number, street)

For example, 95 Shevchenko

City

For example, Chernihiv

Mobile phone number (no spaces in number)

For example, 09677777

E-mail

Country of birth

Ukraine

Country of Domicile

Have you been resident in EU (including UK) for 3 years or more?
*

yes

Have you studied in the UK in Higher Education previously for six months or more?
*

yes

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