Enrolment Form Home Group 6

PERSONAL INFORMATION

To the attention of:

Family name:

First name:

Male Female

Passport number:

Address:

City and postcode:

Country:

Telephone number:

Fax:

E-mail:

Name and contact information of relative/contact (for emergency use only)

Do you suffer from any illness of disability?

Yes No

If yes, please give full details:

Nationality:

First language:

Date of birth:

ARRIVAL AND DEPARTURE INFORMATION

How do you intend travel to England?

Date of arrival:

Point of arrival and travels details if known:

Date of departure:

Point of arrival and travel details if known:

ACCOMMODATION

Homestay start date:

Homestay end date:

Are you allergic to cats ?

Yes No

Are you allergic to dogs ?

Yes No

Do you have any other allergies, special dietary requirements (no meat, no fish, etc.) or is there any other information which might help us choose suitable homestay accommodation for you?

Do you smoke ?

Yes No

PAYMENT DETAILS

Please indicate how you would like to pay:

Bank Transfer Sterling Bank Cheque Credit Card

For payments by bank transfer please note that all bank charges must be included in your payments so that we receive the correct amount for the course.

A deposit of £200 is required with the booking if it is sent more than 1 month before arrival. Payment of full fees must be made one month before arrival.

CREDIT CARD PAYMENTS

Credit card payments are available to individuals, not to agencies.

Payments by credit card can be made securely through our website at this link: https://www.ilh.com/payment

DECLARATION (to be completed and signed by the student's parent or legal guardian)

Student's name:

Parent/guardian's name:

I accept the terms and conditions.

Thank you for completing this enrolment form.