Full name *

First Name

Last Name

Date Of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Country

(###)

###

####

Parent/Guardian (If under 18) *

First Name

Last Name

Emergency Contact Number *

Country

(###)

###

####

Have you previously studied a Level 3 course?

Yes/No

Yes

No

Residency & ID Are you a UK or EU resident?

Yes/No

Yes

No

Can you provide ID (passport, birth certificate)?

Yes/No

Yes

No

Do you have any learning difficulties

Yes/No

Yes

No

I confirm that the information provided is accurate *

CONFIRM

I DENY

I consent to Genesis Esports Academy storing my data under GDPR *

I CONSENT

I DENY

I agree to abide by the Academy’s Code of Conduct *

I AGREE

I DENY

I give permission for GEA to use photos/videos for promotional purposes *

I AGREE

I DENY

Parent/Guardian Contact Number (if under 18):

(###)

###

####

Date of signature *

MM

DD

YYYY