International Centre
tel: 44 (0)1243 536294 fax: 44 (0)1243 775783 www.chichester.ac.uk

Application Formfor International Students
Full-time Courses

Session 20Attach
Photograph
Here- 20

Please complete this form in BLOCK CAPITALSCOURSE DETAILS
Course Dates

Course Required (for English Language courses please state programme)

From:

For English Language
course ONLY

Weekly Hours (English course ONLY)
15hours

20hoursTo:

English-Extra - Please indicate your options

25hours

12

PERSONAL DETAILSFamily NameFirst Names

Gender (please tick appropriate box)
MaleCountry of Birth

FemalePassport Number (please attach a photocopy of your passport)

Marital Status (please tick appropriate box)
MarriedNationality

SingleDate of BirthDo you need to apply for a student visa?
YesNo

CONTACT DETAILSYour Address (If you are under 18 please give your parents’ / guardian’s address)

Your Contact Numbers (please include area code numbers)

Address

Telephone
Fax
MobilePostcode

Email Address

Agent’s Name and Address (if applicable)

Agent’s Contact Numbers (please include area code numbers)Name

Telephone

Address

Fax
MobilePostcode

Email AddressACCOMMODATIONIMPORTANT: Please indicate your 1st and 2nd choices of accommodation

For students aged 16-17 years:e.g.

1 for 1st choice

2 for 2nd choice

For students aged 18 years and above:

Woodlands Halls of Residence
A minimum stay of one year
(Full-board only)

Westgate Hallsof Residence

Homestay
Half-board

Leasing Scheme
Student House

HomestaySelf-catering (For those aged 17+ ONLY)

Homestay
Half-board

Please Note: Internet services can not be guaranteed with Homestay.

Stockbridge Hallsof Residence

HomestaySelf-catering

Please Note: Internet services can not be guaranteed with Homestay.

ACCOMMODATION REQUIREMENTS
Are you willing to share a room?

Yes

No

Are you willing to share with students who
speak the same first language as you?

Yes

No

Are you a vegetarian?

Yes

NoAre there any foods you cannot eat?

Yes

No

If Yes, please state which

If under 18, are you willing to sharewith students who are 18+?

Yes

Do you have any medical problems?

No

Do you smoke?

Yes

No

Are you willing to live in a householdwith smokers?

Yes

No

Many British families have pets.
Please tick the appropriate box(es) ifyou have an allergy to cats and/or dogs.

NoDo you have any special requests regarding accommodation?

Please specify your expected arrivaland departure dates (if known)Yes

If Yes, please state which

Expected Arrival Date:

Please indicate your chosen payment method

MEDICAL DETAILS - All questions MUST be answered
Asthma, Bronchitis or beathing problems?

Yes

NoHeart condition?

Yes

No

Fits, Epilepsy, fainting or blackouts?

Yes

No

Severe headaches or migraines?

Yes

NoDiabetes?

Yes

NoAllergies to medicines, drugs or food etc?

Yes

No

Eczema or other skin disorder?

Yes

No

Other illness or disability?

Yes

No

If you answered yes to any of the questions in this section,please give details (please use the space on the back of this form if necessary)

Dogs

Cats

Expected Departure Date:

Direct to Host

Have you had any of the following:

I have an allergy to:Through the College(Any relevant medical reports should be attached to this form)

Do you have any physical handicap that may
affect your accommodation requirements?

Yes

No

Do you take any medication of any kind,
whether prescribed or not?

Yes

No

Have you been vaccinated against tetanus
in the last 5 years?

Yes

No

Have you received any medical, surgical or
psychiatric treatment of any kind from adoctor or in hospital in the last 3 years?

Yes

No

Medical Information
The medical information you provide will be used to assist us to process your application appropriately.
The information will be shared with relevant parties and only in order to ensure your wellbeing whilst whilst living in College accommodation.
If for any reason you do not want the information to be passed to anyone else, please tick the box below.
I do not want my medical details passed on to any other parties.

EMERGENCY CONTACT
Emergency Contact Address

Emergency Contact Numbers (please include area code numbers)
Fax

Telephone
MobilePostcode

Email Address

HOBBIES & INTERESTS - Please list any hobbies and interests you may have

TRAVEL HISTORY
Have you travelled overseas before?
If Yes, did you stay with a family?

Yes

Yes

Have you visited the UK before?

No

Yes

If Yes, where did you live?

NoNo

ENGLISH ABILITY
Please rate your ability to listen and speak in English:
Please rate your ability to read and write English:
Your ability to communicate in English is:

Excellent
Excellent
Excellent

GoodGoodGood

Poor
Poor
Poor

PAYMENT OF FEES OR DEPOSIT
Who is paying your tuition fees?
Yourself, parents or family

Agent

Other (please specify)

Who is paying your accommodation fees?
Yourself, parents or family

Agent

Other (please specify)

Are you sponsored by the Hong Kong Goverment?

Yes

NoYou may pay your fees, course deposit or accommodation arrangement fee by one of the following methods:(please tick your preferred choice)Cash If you are currently living in the UK you may
Bank Transfer Please ensure that the bank transfer includes the student’s
make your payment at the College. Please do not sendname and attach a copy of the tranfer to this application form. The transfer
cash through the post and we do not recommend
should be made in sterling to:that you travel to the UK with large sums of cash.
Lloyds TSB Bank plc, 10 East Street, Chichester, West Sussex. PO19 1HJ
Bankers Draft You may send a bankers draft inAccount Name:
Chichester College
sterling payable to: Chichester CollegeSort Code:30-91-97Account Number:
BIC:
Iban:

01924620
LOYDGB 21233
GB69 LOYD 3091 9701 924620

Credit Card To pay your fees by switch, Delta, Visa,Mastercard or Solo please complete the credit/debitcard form below

Cheque Please make cheques payable to: Chichester College
I wish to pay by Switch/Visa Delta/Visa/Mastercard (not Electron)
I hereby authorise Chichester College to debit my debit/credit card for the sum ofCard No.
Name on Card

Start Date
Security Code(last 3 digits onreverse of card)£Expiry Date
Issue Number(Switch only)

Registered
Card AddressMail Address(if different)

Signature

DateWHERE DID YOU HEAR ABOUT CHICHESTER COLLEGE?
Please tick the relevant box(es)Advertisement

School, college or university

Agent

Exhibiton / Seminar

Friend or relative

OtherInternet(please state)

PARENTAL PERMISSION (Must be completed if you are under 18 years of age)
Dear Parent/Guardian,Throughout the year the College will be running a variety of day trips and visits. Details will be given on each trip/visit,
however, to ensure the smooth running of the process, we ask that you complete a consent form for your son/daughterto take part in these activities.
I wish my son/daughter(full name of student, in capital letters please)
Date of birth					Student ID No.

To be allowed to take part in College day trips/visits throughout the academic year which begins in September and ends in Julyand I agree to his/her taking part in any or all of the activities described under the conditions set out. I understand that during these trips
students may have free time and will not be directly supervised but that all trip supervisors will be contactable.
I have ensured that my child understands that it is important for his/her safety and for the safety of the group that rules and any instructions
given by thes staff in charge are obeyed.
I understand that, while the college staff and helpers in charge of the party will take all reasonable care of the young people, unless they are
negligent they cannot be held responsible for any loss, damage or injury suffered by my son/daughter arising during or out of the journey.
Note: Your son/daughter will be covered by the College’s insurance in the event of injury incurred during the excursion.
I consent to any emergency medical treatment necessary during the course of the visit.
Signed							DateRelationship
Note: Photographs may be taken that include your son/daughter. If you do not wish such pictures
to be used for normal publicity purposes including the College’s publicity material, please tick this box.

APPLICATION CHECKLISTBefore sending this form please ensure you have completed the following:
Enclosed academic transcripts and certificatesCompleted this form IN FULL

Enclosed payment

Enclosed a copy of your passport

Enclosed English Language Certificate and work experience references

SIGNATURE (Student or Parent/Guardian if student is under 18 years old)
I agree that the information contained on this form can be given to my accommodation provider.

Signature
DateWhilst every effort will be made to meet your specific request, accommodation is limited. The sooner you submit this form the more likely that your needs will
be met. Please return this form, together with your Application Form and deposit to:International Centre, Chichester College, Westgate Fields, Chichester, West Sussex. PO19 1SB ENGLAND
Chichester Campus: Chichester College, Westgate Fields, Chichester, West Sussex. PO19 1SB

Brinsbury Campus: Chichester College, North Heath, Pulborough, West Sussex. RH20 1DL