Book now - Country Cousins

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*

DD slash MM slash YYYY

Nationality*

Country

English level*

MEDICAL AND DIETARY INFORMATION

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

Yes

Please indicate the date of the last vaccination*

Does the student have any allergies?*

Yes

Please indicate what type of allergies*

Does the Student have any dietary requirements?*

Yes

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

Please give details*

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

Is the Student taking any medication?*

Yes

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

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

Does the Student need any support in the classroom?*

Yes

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

Phone of the person who can speak English*

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

MEDICAL

Medical consent*

I agree to Country Cousins staff giving the Student common, non-prescribed medicine, i.e. paracetamol, cough syrup, ibuprophen in case of sickness.

Medical consent*

I agree to Country Cousins staff giving the Student controlled medicines prescribed by a doctor in the Student's country or in England.*

Medical consent*

I give permission for Country Cousins staff, in an emergency, to follow the advice of attending medical staff and to authorise medical treatment and/or anaesthetic for the Student.*

PUBLICITY

Country Cousins takes photographs and videos of individuals and groups of students for use in its publicity material and in social media (Facebook and Instagram mainly). Please tick the boxes below if you are willing for the Student to be included in such group photographs/videos.

I consent to photographs being taken of my son/daughter and used in publicity materials, either individually or as part of a group*

Yes

I consent to videos being taken of my son/daughter and used in publicity materials, either individually or as part of a group*

Yes

I consent to photos/videos being taken of my son/daughter and used on social media platforms, such as Instagram and Facebook*

Yes

TRAVEL

Students will be met and collected from the airport/train station by trained Country Cousins ‘Meet & Greet personnel’ who will be waiting at the Arrivals hall. The student will be accompanied by Country Cousins staff to Country Cousins Devon to begin the course.

I agree for the care arrangements for my child’s travel to, reception and care while in the United Kingdom and confirm that my child has my consent to live and travel independently*

Yes

ADDITIONAL FREEDOM

Country Cousins has curfew times according to the age of students. Students are supervised during the day whilst in lessons and on activities. There are times where the students have additional freedom, for example walking to/from school -home, or meeting up friends on weekends and evenings. For children 11 to 15 years old we will presume they may have additional freedom. Please tick the boxes below accordingly.

I agree with the levels of supervision offered to students at Country Cousins and I am aware on additional freedom around town or with staff members at limited times. https://www.country-cousins.com/about-us/policies*

Yes

The following times indicate when students needs to be back in their accommodation. Up to 10 years old: evening activities only 11 & 12 years old: 9pm 13 & 14 years old: 9.30pm 15 & 16 years old: 10.00pm 17 years old: 10.30pm

DECLARATION

You must sign and agree before submitting this booking form.

Agreement*

I confirm that all the information I have provided is correct to the best of my knowledge.

Agreement*

I confirm that I accept the terms and conditions of enrolment. (please visit www.country-cousins/terms)

Agreement*

I agree with and Country Cousins Discipline & Exclusion Policy.

https://www.country-cousins.com/about-us/policies I will help Country Cousins to ensure that my son/daughter respects the rules of Country Cousins and homestay.

Name*

First Last