APPLICATION FOR ADMISSION TO QUEEN ALEXANDRA’S HOUSE

E:Mail:                queenalex01@gmail.com

Fax:                     020 7589 3177                        Telephone:             020 7589 1120

Post:                    Queen Alexandra’s House, Kensington Gore, LONDON SW7 2QT

Please fill in this form and return it to us by e:mail, fax or post.

Your application must be accompanied by a current photograph and a deposit of £300.00

(If applying by post, please include a cheque for your deposit, otherwise we will send you details upon receipt of

your application on how the deposit can be paid)

First Name:

Surname:

Date of birth:

Will you be under 18 years of age at proposed date of entry to QAH:       Yes   /    No

Nationality:

Home address (including post code):

Contact address (including post code):

Personal telephone number:

Personal E:Mail address:

Fax number:

Proposed college:

Title and length of course:

Music students, please name your instrument/s:

Length of proposed stay at Queen Alexandra’s House: (please circle appropriate choice)

                      1 term                                2 terms                              3 terms

Grade/size of room required:  (please circle one only)

                        A                                           B                                          C

Proposed date of entrance to QAH:

Name of Parent/Guardian:

Address of Parent/Guardian:

Telephone number of Parent/Guardian:

E:Mail for Parent/Guardian:

If your Parent/Guardian IS RESPONSIBLE for the payment of your residential fees, they must sign and date the following declaration:

I declare that as the above-named Parent/Guardian of

……………………………………………………………………………………(enter full name of proposed resident),

I will make full payment of this proposed resident’s fees on or before her date of entry to Queen Alexandra’s House.

……………………………………………………………………                            ………………………………………………..

      (Parent/Guardian signature)                                                 (Today’s Date)

If your Parent/Guardian IS NOT RESPONSIBLE for the payment of your residential fees, you must be 18 years of age or over and personally sign the following declaration:

I ……………………………………………………………………………………(enter your full name) as a proposed resident at Queen Alexandra’s House, will make full payment of my residential fees on or before my date of entry to Queen Alexandra’s House.

……………………………………………………………………                            ………………………………………………..

      (Proposed resident’s signature)                                           (Today’s Date)

Name and address of two referees (e.g. House Mistress, Family Doctor or Parish Priest):

Referee 1:                                                           Referee 2:

Referees address:                                              Referees address:

Details of any disabilities, serious allergy, regular medication or special diets:

Please include any further information you feel is relevant to your application: (e.g. previous educational establishment, recent educational/professional qualifications and/or employment, main interests, and languages spoken).