Times Higher Education Program Application Form

Personal Details
Name Name First Middle Last
Gender

Gender Female Male Prefer not to disclose
Date of Birth Date of Birth / DD / MM YYYY
Are you of Aboriginal or Torres Strait Islander descent?

Are you of Aboriginal or Torres Strait Islander descent? Yes No Prefer not to answer
Are you an Australian citizen?

Are you an Australian citizen? Yes No
Has anyone in your immediate family attended University?

Has anyone in your immediate family attended University? Yes No
Do you have any medical conditions or special needs requirements?

Do you have any medical conditions or special needs requirements? Yes No
If yes, please specify
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Is the above address the same as your postal address?

Is the above address the same as your postal address? Yes No
Postal Address Postal Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Contact Phone Number
Email
School you graduated from in 2018
2018 In2Uni program you participated in
UOW Student ID
Have you received an Early Admission offer to study at UOW in 2019 via UAC

Have you received an Early Admission offer to study at UOW in 2019 via UAC Yes No
I intend to commence my studies at UOW in February 2019 and will continue until November 2019/end of session

I intend to commence my studies at UOW in February 2019 and will continue until November 2019/end of session Yes No
I will be available to attend the program on both Monday 14th January, 2019 (8:30am-3:30pm) and Monday 21st January, 2019 (8:30am-3:30pm), and I will organise my own transport arrangements to and from the UOW Wollongong campus

I will be available to attend the program on both Monday 14th January, 2019 (8:30am-3:30pm) and Monday 21st January, 2019 (8:30am-3:30pm), and I will organise my own transport arrangements to and from the UOW Wollongong campus Yes No
I currently have*/or am willing to obtain a passport at my own cost to travel by June 2019

I currently have*/or am willing to obtain a passport at my own cost to travel by June 2019 Yes No

*your current passport must not expire before December 2019
If my digital story is chosen as the winner, I am eligible and able to travel to the UK from Wednesday 26th June 2019 to Friday 28th June 2019 to present my story at the Young Universities Summit

If my digital story is chosen as the winner, I am eligible and able to travel to the UK from Wednesday 26th June 2019 to Friday 28th June 2019 to present my story at the Young Universities Summit Yes No
Emergency Contact details
Name Name First Middle Last
Phone
Email
Relationship to yourself
Participation in the Times Higher Education Program
University of Wollongong may occasionally use photography and digital media for publicity purposes and showcasing the work of the students. I hereby consent for UOW and/or its representatives, agents and related entities to use any photographs or videos of my appearance, for possible inclusion in UOW publications, websites and other publicity material. I understand that the image will remain the property of the University of Wollongong, and will be used for the designated purpose of promoting UOW.

University of Wollongong may occasionally use photography and digital media for publicity purposes and showcasing the work of the students. I hereby consent for UOW and/or its representatives, agents and related entities to use any photographs or videos of my appearance, for possible inclusion in UOW publications, websites and other publicity material. I understand that the image will remain the property of the University of Wollongong, and will be used for the designated purpose of promoting UOW. Yes No
I have read, agree and adhere to the Terms and Conditions for the Times Higher Education program as outlined on the Outreach and Pathways website.

I have read, agree and adhere to the Terms and Conditions for the Times Higher Education program as outlined on the Outreach and Pathways website. Yes No

Times Higher Education Program Application Form

Times Higher Education Program Application Form

Personal Details

Emergency Contact details

Participation in the Times Higher Education Program