Skip to content
Contact Us!
+44 1271 862834
 |  help@country-cousins.com
Login
Agents Login
Host Families Login
Student Login
Contact us
Become an agent
Homestay Registration
Join the Team
Get a Quote
Brochure
Home
About Us
70+ Years of Learning
About Ilfracombe and North Devon
Awards & Nominations
Become an agent
Blog
Brochure
Channel School of English
FAQ (Frequently Asked Questions)
Homestay Information
Meet the Team
Misson Statement
Our Policies
Photo Gallery
Terms and Conditions
Courses
Academic Placements
Course Certificate
Mini Stays for Groups
Teaching and Learning
Teaching Staff
Trinity College GESE Exams
Our Programmes
Mini Learners (6-10)
Adventure Sports Residential
Adventure Sports
Ball Sports
Beach Volleyball
Exploring Devon
Horse Back Riding
Sea Water Sports
Sports Science
Street Dance
Surfing
Tennis
Student Guide
24 Hour Care
Accommodation & Welfare
Arrivals in Ilfracombe, North Devon
At the Airport
A typical first week
First Day
Insurance
Medical Help
Our PALS
Safe Arrivals
Social Programmes and Excursions
Transfers
Prices
Book Now!
Make a Payment
Prices & Dates
What’s included in the price
Book Now
Search for:
Search for:
May HalfTerm 2021 in Ilfracombe with Country Cousins
Maribel
2021-04-30T13:19:56+00:00
February Half Term 2022 - Student Consent Form
STUDENT PERSONAL DETAILS
Name
*
First
Last
Male/Female
*
Male
Female
Telephone
*
Email
Date of Birth
*
dd/mm/yyyy
Nationality
*
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Saint Martin
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Please indicate your preferences
*
19th - 27th February Full board in a homestay environment
Homestay £45 per night
MEDICAL AND DIETARY INFORMATION
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
Is the Student taking any medication?
*
Yes
No
Please give details, including medication name, dose, how often and when it is taken.
PARENT/GUARDIAN CONTACT DETAILS
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Email
*
Mobile Phone
*
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 iin 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.
ADDITIONAL FREEDOM
There are times where the students have additional freedom, for example when an outing to go shopping. 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.
*
Yes
No
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.
Name
First
Last
Δ
Page load link
Go to Top