Studient details and parental consent

STUDENT PERSONAL DETAILS

Name*

First Last

Male/Female*

Male
Female

Telephone*

Email

Date of Birth*

dd/mm/yyyy

Nationality*

Arrival date to Homestay

Departure Date

Do you need us to arrange a taxi to and from school?

Yes
No

Please let us know at what time you will be arriving to the homestay and what time you will be picked up on departure

Please select if the student would be interested in any of these activities during the stay with us

Tennis
Croyde to Crow point coastal walk
Arlington Court, Regency House and Carriage Collection
Surfing at Croyde beach
Daytrip to Exmoor National park
Daytrip to Exeter
One or two nights in London including a musical from £550 aprox.

We might be organising activities while you stay with us. You are very welcome to join in. Each half day activity at 13:30 will be £10 (Tennis £5) Full day trip £20 Adventure and water activities £30

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/ homestay host 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/homestay host 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/homestay host, in an emergency, to follow the advice of attending medical staff and to authorise medical treatment and/or anaesthetic for the Student.