APPLICATION FORM Shakespeare in Stratford Study course at The Shakespeare Birthplace Trust Stratford-upon-Avon Sunday 7 – Saturday 13 August 2011 (inclusively) Deadline for applications: Friday 13 May 2011 Please read the accompanying guidelines before completing the form Completed forms should be returned to: Education Department- education@esu.org
Personal Details Please attach a passport sized portrait photograph of yourself to the front sheet Title: First Name:
Family Name:
Other names: Please indicate by which name you prefer to be known, by circling it Date of birth:
Gender:
Place of birth:
Nationality:
Emergency contact details Name: Relationship to you: Phone number dialling code: Contact details Address to which all correspondence should be sent: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Home/ Mobile phone: _______________________ Work phone: ______________________ Email: What is the best way of contacting you: _________________________________________ Dietary requirements
Please let us know if you are vegetarian or have other medical/ethical dietary requirements. Though we will endeavour to insure that all dietary requirements will be catered for, it cannot be guaranteed at all meal times. Please tick
o I am vegetarian
o I have other dietary requirements
[Please give details below] _________________________________________________________________________ _________________________________________________________________________ Health Please include details below of any medical conditions you may have or medication you are taking and of which we should be made aware. [These details will remain confidential] _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Academic/Employment details Please fill out the relevant sections – see notes for details Current Occupation: Current place of employment/study: Please list all institutions of education attended from the age of 18 and qualifications obtained. Name of Institution
Dates From
Qualifications obtained, year and grade To
Languages spoken (please state whether advanced, intermediate or basic): Language
Level/Qualification
Please list your interests and achievements:
_________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________
Specific experience relevant to application:
Please declare if you have already participated in an ESU programme, please specify which one and whether you received a scholarship place.
Personal statement All applicants must complete this section of the form Please use a separate sheet to explain, in no more than 400 words, how you think you would benefit from the ESU Shakespeare in Stratford Study Course Shakespeare Birthplace Trust and how the experience would help you in your current work and future ambitions. Please mention how you currently use Shakespeare within your work and what you would like to learn from the course.
I have read and understood the notes and conditions for applying for a scholarship to the ESU. Declaration I declare that the information given above is correct: Signature
Date: