Application Form Medical Foundation Course

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Section 1: Details of the Applicant
Please use the name as seen on your passport
Family Name*
Forename(s)*
Marital Status*
Maiden Name (if applicable)
Date of Birth*
Present Age*
Gender*
- Male
- Female
Nationality*
Religion*
City of Birth*
Region of birth:*
Country of birth*
Passport No. (for overseas applicants):
Place of issue
Address*
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Home Phone*
Mobile Phone*
Email*
Address for correspondence, reports and fees payment (if different)
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Home Phone
Mobile Phone
Email
Who will be responsible for paying fees? Please state relationship to student:*
Contact details (if different from above):

Section 2: Health Insurance
Name of Parent or Guardian:
First Last
Does the Applicant take medication on a regular basis, or have any health issues?*
- Yes
- No
If yes, please give details separately.
We advise all students to take adequate health and personal insurance. Would you like the college to assist with this?*
- Yes
- No

Section 4: Course Details
Which subsequent degree course do you wish to apply for?*
- Medicine
- Dentistry
- Pharmacy
- Physiotherapy
- Other
Which entry date on the course do you wish to start?*
- September Entry
- anuary Entry (for able applicants only, including minimum IELTS English level of 5.5 – if unsure please ask)

Section 5: Your English Language Level
Your English Level
- I am a native speaker of English, from a country whose first language is English (see country list on website)
- I am not a native speaker of English but I have an English Language equivalent IELTS level of 6.0 or above
- I am not a native speaker of English but I have an English Language equivalent IELTS level of 4.5-5.5
Native speakers of English, and non-native speakers with an IELTS equivalent level of 6.0 or better, will not normally require additional English Language lessons. Those with IELTS equivalent level of 4.5-5.5 will require additional English Language lessons as a compulsory additional part of the course; these will be invoiced at €1710 for September starters or €570 for January starters. Applicants below IELTS equivalent level of 4.5 are not suitable for this course; please contact us for pre-sessional options. Please tick which of the following applies:
Part B
- I have an official English Language qualification
- I have no English qualification
(You will need to have a Skype interview and/or written assessment so we can test your level before proceeding if no English qualification
Please attach a copy with full details including date taken

Section 6: Details of Academic Record and Qualifications
To be completed by all Academic students only
Name of Secondary School or College:
Address of Secondary School or College:*
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Year of Graduation
Name of University or Higher Education Institution if applicable:
Address of University or Higher Education Institution if applicable:*
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Full Course Title
Year of Graduation
EXAMINATIONS ALREADY TAKEN AND TO BE TAKEN.
Please use a separate sheet if needed to list examination subjects, grades and dates and enclose copies of all certificates obtained to date. Please make it clear if results given are actual or predicted results (if predicted a letter should be attached to this application from the school/college with the predicted grades).

Section 7: Personal Statement
Upload Personal Statement Here
Please attach a typed personal statement to tell us about yourself and your interests. In particular explain why you wish to pursue your chosen course of study. Statements should be no longer than one A4 typed sheet.

Section 8: Visa
Do you require a visa to study in the Czech Republic?
- Yes
- No
British and other EU students do not currently need a visa.

Section 9: Preferred Accommodation
What accommodation would you prefer?*
- Standard (twin room, private bathroom)
- Single (single occupancy, private bathroom)
See fees list for supplements

Section 10: Declaration by Parent/Guardian or Sponsor
I apply to enrol the student named in Section 1 of this form for a Foundation Course in Prague. I undertake to pay all relevant fees and charges on or before the date on which they become due.
Name in full of person signing*
First Last
Date*
Relationship to Applicant
Additional signing by applicant*
First Last
Date*
I am sponsoring myself - print name*
First Last
Date*
If paying the €245 Registration Fee by bank transfer please include a copy of the confirmation of bank transfer with your application.
The bank details for transfers are as follows: Bank Lloyds Plc. Branch Queen Sq. Wolverhampton A/C Name The Abbey College in Malvern Ltd. A/c No 86550006 Sort Code 30 99 83 SWIFT BIC LOYDGB21114 IBAN GB42 LOYD 3099 8386 5500 06
I have transferred the sum of €245 on

Section 1: Details of the Applicant