Academic Pathways Booking - Country Cousins

YOUR COURSE

First lesson start date*

Number of weeks*

Your Programme for 2 weeks*

4 weeks Programme*

Do you have a promotion Code or Agency name?

Promotion Code

Agency or Agent name

Promotion Code

Please note: This code will be applied in your invoice.

Agent or Agency name

YOUR ACCOMMODATION

Accommodation type*

Arrival day*

Your booking total

The above is a summary of your booking information and current booking availability. Please review these details to ensure they are correct before moving onto the next step.

STUDENT DETAILS

Name*

First Last

Male / Female*

Male

Female

Telephone*

Email*

Other information

Date of birth*

Nationality*

English level*

MEDICAL AND DIETARY INFORMATION

Has the student been fully vaccinated for Covid-19?*

Yes

No

Please indicate the date of the last vaccination*

Does the student have any allergies?*

Yes

No

Please indicate what type of allergies*

Does the Student have any dietary requirements?*

Yes

No

Please indicate what type of diet requirements*

Vegetarian

Vegan

Gluten free

Lactose free

No red meat

No pork

No fish

Please not that extra cost will be applied in your invoice for dietary requirements.

Does the Student have any medical condition or physical/mental disability?*

Yes

No

Please give details*

E.g. visual impairment, hearing impairment, asthma, fainting, headaches, bed wetting, incontinence,...

Is the Student taking any medication?*

Yes

No

Please give details, including medication name, dose, how often and when it is taken.*

WELFARE INFORMATION

Does the Student need any help with mobility?*

Yes

No

Please give details.*

Does the Student need any help with social interaction, for example, is the student shy? Is it difficult for him/her to make friends?*

Yes

No

Does the Student need any support in the classroom?*

Yes

No

If yes, please give details*

E.g. is the Student dyslexic?

PARENT/GUARDIAN CONTACT DETAILS

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Home telephone

Work telephone father

Work telephone mother

Mobile father*

Mobile mother*

Student's mobile*

Please note: we will add this number to a whatsapp group for communications during your stay here only

Does the parent/guardian named above speak some English?*

Yes

No

Phone of the person who can speak English*

Please indicate the number of the person who can speak English in case of an emergency

YOUR COURSE

YOUR ACCOMMODATION

STUDENT DETAILS

Other information

MEDICAL AND DIETARY INFORMATION

WELFARE INFORMATION

PARENT/GUARDIAN CONTACT DETAILS

MEDICAL

PUBLICITY

TRAVEL

ADDITIONAL FREEDOM

DECLARATION

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