Form code block Step 1 of 4 25% Agency or School group detailsCompany name* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Contact name* Contact mobile number* Email* Transfer detailsArrival date* DD slash MM slash YYYY Departure date* DD slash MM slash YYYY Airport / Station*London HeathrowBristol airportExeter airportLondon St. Pancras train stationLondon VictoriaI don't need transfer for my groupOtherComments Please use the space for any comments. Specially if you have selected "Other" or " I don't need transfer for my group"Arrival Flight details Departure Flight details Group detailsListFirst NameSurnameSexDate of Birth dd/mm/yyyyProgramme ChoiceEnglish LevelStudent's mobile numberEmergency mobile numberAllergies/Diet requirementsParental consentSharing room with FMOtherPrefer not to sayMini StayExploring DevonAdventure SportsBalls SportsBeach VolleyballFootballMusical Theatre AcademyRidingSea Water SportsSport ScienceStreet DanceSurfingTable TennisTennisNot sureA2B1B2C1C2None reportedAllergy-animals'hairAllergy-nutsAllergy-ashmaDiet-Gluten freeDiet-Lactose freeDiet-VegetarianOtherYESNO Please indicate in the column above if you have consent from the students's parents for the following: - Photos and Videos being taken of the student and used in publicity materials or social media either individually or as part of a group. - Additional Freedom. Parents agree with the levels of supervision offered to students at Country Cousins and are aware on additional freedom around town or with staff members at limited times. For children aged 11-15 they will presume students may have additional freedom. Student's with no parental consentFirst NameSurnameConsent to Photo/VideosConsent to Additional Freedom YesNoYesNo Please indicate students names if they haven't been authorised to be part of the photos/videos used in publicity materials or social media either individually or as part of a group, and Additional freedom. • Social Media- Consent for photograph/videos of the student used on social platforms, such as Instagram/Facebook either individually or as part of a group Group Leaders detailsHow many Group Leaders are coming with your group please?Please select a number and complete their details below. 1234ListFirst NameSurnameSexDate of Birth (dd/mm/yyyy)Contact mobile numberNext of Kin number for emergenciesAllergies/Diet requirementsSafeguarding Awareness OnlinePolice Checks Certificate FMOtherPrefer not to sayYesNot YetYesNoNot Yet Please complete the online course as soon as you can https://accreditation-uk.english.britishcouncil.org/Safeguarding CertificatesPlease note that each group leader should have its own certificate. Drop files here or Select files Max. file size: 256 MB. Police Checks CertificatesPlease note that each group leader should have its own certificate. Drop files here or Select files Max. file size: 256 MB. Consent* By signing below, I agree on behalf of the Agency detailed above, to the following stipulations:Country Cousins documents and terms and conditions above. • We confirm that the above details are accurate and complete • We agree to Country Cousins terms and conditions • We agree we have obtained individual parental consent for each of the following areas: Photos/Videos and Additonal Freedom Δ By Yannovich|2019-01-07T12:22:54+00:00January 7th, 2019|Comments Off on Form code block Share This Story, Choose Your Platform! FacebookTwitterRedditLinkedInWhatsAppTumblrPinterestVkEmail About the Author: Yannovich
