Name:
College/school:
Date of Birth (dd/month/yy):
----
01
02
03
04
05
06
07
08
09
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
----
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
Home Address Line 1:
Home Address Line 2:
Home Address Line 3:
Post Code:
em@il:
Confirm em@il:
Telephone:
Category:
A work of fine art
Digital art/animation/game
Topic:
Diversity or Disorder
The (St)ages of the Brain
I would like to discuss this with you
Please give details of your current GSCE/AS/A-level courses and your relevant hobbies and interests:
Are you interested in a summer placement?
Yes
No
Can we publish your photo on our website or in the press?
Yes
No
We are more than happy to discuss the projects and talk about the science with you. If you have any comments or questions, please enter them below.
Comments / Questions: