Apply to 2017 Women in STEM Residential Step 1 of 2 50% Personal DetailsYour Name* First Name Surname Date of Birth* Email Address*Please make sure your email address is spelt correctly as if there are any mistakes we won't be able to contact you. How would you describe your gender?*How would you describe your ethnicity?*Address* Street Address Address Line 2 City ZIP / Postal Code Academic DetailsWhat school year are you currently in? Year 12 (Northern Ireland Year 13/Scotland S6) Year 11 (Northern Ireland Year 12/Scotland S5) Other Subject 1*A level or equivalentSubject 2Subject 3Subject 4Subject 5Subject 6GCSEs*Please summarise your GCSE results if you already have them, or your predictions if you are in Year 11Which subject(s) are you thinking of studying at university?Preference 1*Preference 2*Please outline why you would like to attend this residential:* Additional InformationLevel of Education of Parent/Guardian 1: Don’t know/prefer not to answer No formal qualifications GCSE/CSE/ O-level A-level /HNC/BTEC Vocational qualification HND/other Higher Education certificate Undergraduate Degree Masters Degree PHD Level of Education of Parent/Guardian 2: Don’t know/prefer not to answer No formal qualifications GCSE/CSE/ O-level A-level /HNC/BTEC Vocational qualification HND/other Higher Education certificate Undergraduate Degree Masters Degree PHD Have you ever been entitled to Free School Meals?YesNoPrefer not to sayDo you have a disability or medical condition which affects your studies?YesNoPrefer not to sayHave you ever been in care?YesNoPrefer not to sayAre you a carer for a parent/guardian or any other member of your family?If there are any particular circumstances that you wish to disclose that may have had a negative impact upon your education, please give details here:Your School InformationName of School*School TypeState ComprehensiveState GrammarState Sixth FormIndependentHome-schooledSchool Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Your Nominating Teacher* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Nominating Teacher's Email Address:*Please make sure this is spelt correctly - without an accurate email address we will be unable to contact your teacher. CAPTCHANameThis field is for validation purposes and should be left unchanged.