Your Information YOUR Name (required) LAST / FAMILY Name (required) Date of Birth (dd/mm/yy) (required) Gender: MaleFemale COUNTRY of Origin/Birth PASSPORT Number (required) HOME ADDRESS (required) PHONE (incl. country & area codes) Your EMAIL (required) Emergency Contact Person CONTACT FULL NAME (required) CONTACT PHONE Number (required) (incl. country & area codes) RELATION TO YOU CONTACT E-MAIL (required) English Programme SCHOOL NAME START DATE (mm/yy) END DATE (mm/yy) LOCATION / ADDRESS LEVEL OF ENGLISH: Pre-intermediateUpper-intermediateBeginnerIntermediateAdvanced Homestay Information START DATE (mm/yy) END DATE (mm/yy) Do you have special dietary requirements? If yes, please indicate below. (For example, are you a vegetarian?) Do you have any allergies? If yes, please indicate them: Do you take any medications. If yes, please indicate them: Please list your Hobbies/Interests: Can you live with pets? YesNo Do you smoke? YesNo Can you live with young children? YesNo Airport Transfers ARRIVAL DATE AND TIME FLIGHT # Do you need airport pickup? YesNo Payment & Other Information How will you pay? Wire transferBank draft or certified checkCredit Card Enrolment conditions and refund policy I have read and agree to be bound by the Terms & Conditions and the Payment and Refund Policy (select the checkbox if you agree) I agree My payment deposit will be made at least four weeks prior to the school start date (select the checkbox if you agree) I agree How did you hear about us? (e.g., search engine--please specify; friend, agent): Please enter the following code: This 'code' is to validate that you are a person & not an Internet spambot. Your application will be reviewed and processed once received. At this point we will send you an invoice with our simple payment procedures.