exscitec

Please provide details of your child

* First Name:

* Last Name:

* Position: Please select Student Parent/Guardian Teacher Other (please specify)

Other Position:

* Gender: Please select Male Female

* School:

* Local Authority:

* Year Group: Please Select Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9 Year 10 Year 11 Year 12 Year 13 University Student not a student

* Date of Birth: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

* Email Address:

* Contact telephone 1:

Contact telephone 2:

Student Home County: Please select Bedfordshire Berkshire Buckinghamshire Cambridgeshire Cheshire Cornwall Cumberland Derbyshire Devon Dorset Durham Essex Gloucestershire Hampshire Herefordshire Hertfordshire Huntingdonshire Kent Lancashire Leicestershire Lincolnshire London Middlesex Norfolk Northamptonshire Northumberland Not Set Nottinghamshire Oxfordshire Rutland Shropshire Somerset Staffordshire Suffolk Surrey Sussex Warwickshire Westmorland Wiltshire Worcestershire Yorkshire

Student Home Postcode:

• If you are a school student, please indicate if you
  are registered on either of the following lists?
• Aim Higher
• Gifted & Talented
•  
• * required fields

Below is for OPTIONAL additional detail, useful for
improving the accuracy of our reporting

Where did you hear about Exscitec?

Course Enquiry

If you are a student you must select a year group to see this list

Please use the enquiry form to tell us the course(s) that interest you. We will update you with further information as it becomes available:

(Hold Ctrl to select multiple - max 2):

Any other questions, comments, or detail about the types of STEM activities that interest you:

By submitting this form you are consenting to the details you provide being held on the Exscitec database (please contact us at any time if you wish us to remove your details from the database)

We require your explicit consent to process the data you have provided, which is retained in accordance with the principles as set out in the UK data protection act (1998). Exscitec may be required to share appropriate data only with third parties directly involved in the organisation of activities in which you have expressed an interest. You may request that we remove your data at any time.

You must read our Terms and Conditions before submitting this form.

 Please tick this box to confirm that you give consent for the above use of this data and that you have read the terms and conditions
We cannot process this application without your consent.