May HalfTerm 2021 in Ilfracombe with Country Cousins

STUDENT PERSONAL DETAILS

Name*

First Last

Male/Female*

Male
Female

Telephone*

Email

Date of Birth*

dd/mm/yyyy

Nationality*

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 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.*