Guardianship Application Form

STUDENT PERSONAL DETAILS

Full name*

First Last

English name (if appropriate)

Nationality*

Date of Birth*

dd/mm/yyyy

Gender: How does the student identify?

Male
Female
Transgender
Do not identify as female, male, or transgernder

Passport number

Expiry date of passport

dd/mm/yyyy

Current email address of student

Start date at school

dd/mm/yyyy

Name of English School

Boarding house (if known)

Year group at school

First language

Other languages spoken

Student photo

Accepted file types: jpg, jpeg, png, gif.

Hobbies and interests

MEDICAL AND DIETARY INFORMATION

Does your child suffer from any health problems?*

Yes
No

Please give details of any health problems

Does your child have any allergies?*

Yes
No

Please indicate what type of allergies

Does your child 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

WELFARE INFORMATION

Details of student's personality

Please list any information about the student you think will help them settle in and feel at home with a host family (likes/dislikes/favourite food)

Will the student be returning home for the half term break?

Yes
No

PARENTS CONTACT DETAILS

Mother's full name

First Last

Occupation

Mother's email*

Phone (home)

Phone (work)

WeChat ID

Mother's home address

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

Father's name

First Last

Occupation

Father's email*

Phone (home)

Phone (work)

WeChat ID

Father's address

Same as Mother's address
Other Address

Father's home address

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

EMERGENCY CONTACT INFORMATION

Do any of the parent/guardian named above speak some English?*

Yes
No

Phone

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

Please indicate full details of who to contact in an emergency

Would you like to notify us of any special permission or consents either given or withheld?

Do you have any relatives or friends in the UK?

Yes
No

Name

First Last

Address

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

Email

Phone

Connection to child

TRAVEL

I agree for the care arrangements for my child’s outing while in the care of their Homestay provider or Country Cousins staff. I confirm that my child has my consent to participate in any outings he wants.*

Yes
No

DECLARATION

You must sign and agree before submitting this booking form.

Terms & Conditions*

I agree to the Terms & Conditions

Please see Country Cousins' Guardianship and Parents Agreement

Name

First Last

Guardianship Form

STUDENT PERSONAL DETAILS

MEDICAL AND DIETARY INFORMATION

WELFARE INFORMATION

PARENTS CONTACT DETAILS

EMERGENCY CONTACT INFORMATION

TRAVEL

DECLARATION

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