Fee status assessment * indicates a mandatory question SECTION A Child's full name Child's University ID number Child's date of birth (dd/mm/yyyy) Parent/ Guardian full name Parent/ Guardian telephone number Parent/ Guardian Email address Parent/ Guardian address Address Line 1 Address Line 2 City County Postcode Country EMERGENCY CONTACT Please complete if the contact in case of emergency is different from above Emergency contact name To be contacted in case of emergency (if different from parent/ guardian above) Emergency contact telephone number Emergency contact Email address Emergency contact address Address Line 1 Address Line 2 City County Postcode Country SECTION B Please complete Section B if you (the parent/ guardian) are living outside the UK UK Guardian full name You must complete this section if you (the parent/guardian) are living outside the UK. The University must obtain the details of a UK guardian to be contacted in case of emergency. Please enter N/A if you (the parent/guardian) are living in the UK. UK Guardian telephone number UK Guardian Email address UK Guardian address Address Line 1 Address Line 2 City County Postcode Country Declaration By completing and submitting this form you are subject to its terms. Please note: The data you provide in this form will be held by the University for the purposes set out in the Parental /Guardian Agreement. For more information on how we process your data, please go to https://www.birmingham.ac.uk/privacy/index.aspx . I have read and understood the Parent/ Guardian Agreement and agree to its contents, including: While at the University, my child will be subject to UK law and the University’s rules I am liable for my child’s debts to the University, such as tuition fees and accommodation fees My child may attend University activities without my specific consent and my child must notify the University of any medical conditions. Other than the information covered in the agreement around emergency situations, I understand that the University must have my child's consent before disclosing any information. The University may pass my contact details to any hospital where my child has been admitted so that it can contact me direct regarding my child’s condition. Declaration of consent Name First name Last name Date (dd/mm/yyyy) Today’s date (date of application) Submit