Stripe Test for Short Courses stripe test About youInformation about you and your contact details.First Name of Student Attending(Required)Surname of Student Attending(Required)Gender pronouns of Student Attending--She / HerHe / HimThey / ThemPrefer not to sayDate of Birth of Student AttendingDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Your Email Address(Required) Your Mobile Phone NumberStreet AddressThis field is hidden when viewing the formAddress 2This field is hidden when viewing the formTown/CityThis field is hidden when viewing the formCountyPostcodeEmergency Contact InformationIf you're under the age of 18, we require the name(s) of the parent(s) who consent to you studying at ACM. If your emergency contacts live at different addresses, please provide the address that is nearest to your ACM campus.1st Emergency Contact NameWhat is their relationship to student attending?1st Emergency contact telephone number1st Emergency contact email addressDo you give us permission to speak to this emergency contact?--YesNo2nd Emergency Contact Name (optional)What is their relationship to student attending? (optional)2nd Emergency contact telephone number (optional)2nd Emergency contact email address (optional)Do you give us permission to speak to this emergency contact? (optional)--YesNoCourse selectionWhich course are you interested in studying? If you don't have a preference yet, choose 'I'm unsure' from any section.Choose your preferred ACM CampusChoose a campusBirminghamGuildfordLondonACM Works (CLOCK)ACM RemoteChoose a preferred Study LevelSelect your study level– Fill Out Other Fields –Preferred Year of EntryThe year you'd like to start– Fill Out Other Fields –Preferred Subject AreaSelect your course– Fill Out Other Fields –Admissions assessmentA few questions we need to ask to process your application.Is the student attending a UK citizen?--YesNoEligibility to study--Settled in the UKI require a student visaDoes the student attending have any criminal convictions or ongoing investigations?--YesNoDoes the student attending have any additional needs or disabilities that we can support you with?--YesNoLearning / Health information--2 or more impairments and or disabling medical conditionsA specific learning difficulty such as dyslexia, dyspraxia or ADHDA social/communication impairment such as Asperger's syndrome/other autistic spectrum disorderA long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, or epilepsyA mental health condition, such as depression, schizophrenia or anxiety disorderA physical impairment or mobility issues, such as difficulty using arms or using a wheelchair or crutchesDeaf or a serious hearing impairmentBlind or a serious visual impairment uncorrected by glassesA disability, impairment or medical condition that is not listed aboveDoes the student attending currently or has ever been subject to an Education Health and Care Plan (EHCP)?--YesNoPlease provide the dates of this planCourse PaymentShort CourseACM’s new January Short Course Series gives creatives, performers, producers and future industry professionals the chance to learn practical, career-focused skills in just a few weeks. Price: Total Credit Card I consent to ACM storing and processing the information above in accordance with my application to this study programme and to contact me in the future using the contact details I have provided. NB You can withdraw consent, opt out of receiving further communications and/or find out more about ACM’s use of data and your rights by clicking here.(Required) Accept This field is hidden when viewing the formqr_referThis field is hidden when viewing the formgclid_fieldNameThis field is for validation purposes and should be left unchanged. Δ