Withinsightedu Application Form

Insight2Uni Mentee Application form

Profile

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Your First Name:*

Your Surname:*

Are you in Sixth Form or College?*

What is the name of current School?*

Contact Information

What is your contact number?*

Please type your personal email*

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Information

Please type your House/Flat Number*

Please type your Street Address Line 1*

Please type your Street Address Line 2

Please type your Town*

Please type your County*

Please type your postcode*

Please provide the name(s) of your Head of Year.*

Please provide the email(s) of your Head of Year.*

Date of Birth

What is your date of birth?*

Ethnicity

What is your ethnicity?*

Background

Background information*

Are you an asylum seeker?

Eligible for free school meals

Ever been in local authority care

Have a disability

None of the above

Parent/carer university educated

If you ticked the box that states you have a disability, please tell us what it is and explain what, if any, additional support you need from us?

University

University thoughts: (Let us know if you have any universities in mind)

Programmes

Are you on any other university access programmes? (yes/no option answers) If yes, please let us know which one(s)*

Degree Subject

BTEC

A-levels

GSCE

Please let us know your GCSE grades.*

Professional Areas

Briefly explain what you hope to gain from being mentored? Are there any particular areas you would like to cover with your mentor, or support you would like to receive?*

General Interests

Barriers for Success

Which challenges are you currently facing?

Preferences

Do you have any specific preferences about who you would like to be mentored by?

What is your gender?*

Marketing

We’d like to keep in touch to tell you more about our programmes and alumni network. Are you happy for us to contact you with further information about our work?*

Parental permission

I consent to my child participating in the With Insight Education mentoring programme.*

Please ask your parent/carer to read through and sign this section before submitting your form. Please indicate your permission preferences for your child below:

With Insight Education and our partners on this programme would like your permission to capture photographs, videos and quotes from your child and have full rights to use the content for fundraising, marketing or other publicity-related purposes. This might include (but is not limited to), the right to use them in their printed and online publicity, social media, press releases and funding applications. I consent to With Insight Education taking photographs and/or videos of my child and capturing quotes from them*

If my child is happy to do so, I consent to them continuing to be in contact with their mentor after the programme finishes.*

Please type your Name of Parent/Carer*

Please type your Parent/Carer mobile number*

Please type your Parent/Carer email address*

Data protection

The data collected here will be processed by With Insight Education in accordance with the Data Protection Act 2018 and the General Data Protection Regulation. It will be kept in a secure database for as long as we need in order to track your progress through higher education. It will be used to administer participation in the scheme as well as to conduct database analysis and quality assurance checks. With Insight Education and its partners will not use your data in a way that would affect you individually, and we will not release data to anyone who is unauthorised. Should you wish to opt out of sharing your data, please contact With Insight Education at mentoring@withininsightedu.org Under the Data Protection Act 2018 and the General Data Protection Regulation you have the right to request a copy of the information that we hold about you. You may also ask us to correct or remove any information you think is inaccurate or opt out of sharing your data at any time. If you wish to do this, please contact mentoring@withininsightedu.org.*

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