Cambridge Easter Revision Registration Form

If you have any questions please email us at CambridgeEaster@mpw.ac.uk

or call: 01223 350 158

Student Details

Title

First Name(s) (given)

Middle Name

Family Name

Preferred Name

Date of Birth (dd/mm/yyyy)

Gender

Year Group

Student's Email

Home Telephone

Student's Mobile

Current School or College Details

Name of School/College

Street

City

County

Post Code

Country

Fee Payer's Details

Relationship to Student

Title

First Name

Family Name

Email

Day-time Telephone

Mobile

Fee Payer's Address

Street

City

County

Postcode / Zip Code

Country

Emergency Contact Details

Please provide the details of person (in the UK) who can be contacted in the event of an emergency (if different from above)

Relationship to Student

Title

First Name

Family Name

Email

Day-time Telephone

Mobile

Emergency Contact Address

Street

City

County

Postcode / Zip Code

Country

Student Availability

Dates Available (Select all that apply)

Week 1: Monday 25 March – Friday 29 MarchWeek 2: Monday 1 April – Friday 5 AprilWeek 3: Monday 8 April – Friday 12 April

Registrations cannot be confirmed until full details are provided. Please refer to the Course Outlines booklet when completing this section.

Subject To Be Studied

Level

Subject

Exam Board

Predicted Grade

Specific Weaknesses

GP Details

Name of GP

Street

City

County

Post Code

Country

Medical Details

Does the student have any condition which is, or may be, life threatening?

YesNo

Please provide details

Please provide details of any medical condition which could affect the student's college life:

(e.g. physical disability, asthma, epilepsy, diabetes, heart disorder, deafness, depression, anorexia nervosa, etc)

Please provide details with dates of any serious injuries, illnesses or surgical operations:

Please provide details of any medication being taken:

Please provide details of any allergies:

(including allergies to drugs, especially Penicillin)

Please provide details of any other conditions which could affect the student's college life:

(e.g. anxiety, depression, phobias, PTSD, insomnia etc)

Accommodation

Is Accommodation Required?

YesNo

Accommodation Details

Please tick date as appropriate:

Week 1: 24 March – 29 March (£630)Weekend 1: 30 March - 31 March (£270)Week 2: 31 March – 5 April (£630)Weekend 2: 06 April - 07 April (£270)Week 3: 07 April – 12 April (£630)

Weekend 1 - Notice

Interim weekend at Corpus Christi College

Only available for students attending Week 1 courses and staying for Week 2 courses.

Lunch is not provided at the weekend - not details on accommodation leaflet

Weekend 2 - Notice

Interim weekend at Corpus Christi College

Only available for students attending Week 2 courses and staying for Week 3 courses.

Lunch is not provided at the weekend - not details on accommodation leaflet