Please note that an interview has to be arranged before filling in this form. Thank you! Courses Please check one or various boxes * English + Activities JSP English + Activities / Sailing / Windsurfing English + Immersion Irish Camp School Term School Year Please write in any option Term * Term 1 Term 2 Term 2 and 3 Term 3 Type of Accomodation * Host Family Residence Type of Accomodation * Host Family Boarding Starting Date * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20222023202420252026 Finishing Date * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20222023202420252026 Student Details Name * Surname * Gender * Male Female Date of Birth * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044 Nationality * Passport Number * Expiry Date * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year201420152016201720182019202020212022202320242025202620272028202920302031203220332034 Address * Postal Code * Town or City * County Country * Phone Number Email Level of English * Beginner Elementary Pre-Intermidiate Intermediate Upper Intermediate Advanced Have you taken any exams? * eg: Cambridge, Trinity... What languages do you speak? * Height * Clothing Size * Character * Hobbies and Interests * Appetite * Poor Average Good Allergies, diets and medical information if any Do you mind having pets in the host family? * Religion * Has to practice Own discretion Non practising Place in Family * Eldest Middle Youngest Only Child How many bothers do you have? How many sisters do you have? Parents' or Guardian's Details Father's Name and Surname * Father's Mobile Phone * Father's Occupation * Father's Email * Mother's Name and Surname * Mother's Mobile Phone * Mother's Occupation * Mother's Email * Do parents live together? * Yes No How did you hear about us? * Terms and Conditions http://www.learn-away.com/ca/node/35 I have read and accept all the terms and conditions * CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
