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NEW Outreach Planetarium Ambassadors - Sign up form
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Preferred Name
Your answer
Gender
*
M / F
Your answer
Date of Birth
*
DD/MM/YYYY
Your answer
Email Address
*
Your answer
Mobile Number
*
07 xxx xxx xxx
Your answer
Department
*
Your answer
Course Title
*
Your answer
Level
*
UG / PG
Your answer
Year of Study
*
Your answer
Year of Graduation
*
Your answer
CID (If studying at Imperial College)
8 digits
Your answer
IC Swipe Card Number (If studying at Imperial College)
6 digits
Your answer
National Insurance Number
*
Eg. QQ 12 34 56 A (or submit 0 if you do not have one and get in touch to find out how you can obtain one)
Your answer
Emergency Contact Name
*
Name Surname
Your answer
Emergency Contact Number
*
07 xxx xxx xxx
Your answer
Relationship to You
*
Your answer
T-shirt Size
*
S / M / L / XL
Your answer
Medical Conditions / Allergies
*
Your answer
Dietary Requirements
*
Your answer
Statement/Experience
*
Please provide us with a brief statement as to why you would like to be a Planetarium Ambassador” (max 250 words)
Your answer
Referee's name
*
(For a character reference. This could be your current personal tutor or a teacher from the school you went to.)
Your answer
Referee's email
*
Your answer
Referee's phone number
*
Your answer
Referee's relationship to you
*
Your answer
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