form

Travel details
AGE* TYPE OF PROGRAM ARRIVAL DATE DEPARTURE DATE
Personal Details
Title (Mr,Mrs,Miss,Ms etc…) *
    Passport country *
Gender *
First name* Family name*
Birth date * Country of birth
Marital Status *
Home Address Postal Address (if different)
Region/Count *
Postal Ccde*
Country*
Phone/Mobile*
Email*
Personal Details
Please give details of the last two educational establishments attended.
Educational Qualifications
Please state your level of English.
Advance
References
Please give details of two people we might contact for references
Title (Mr., Mrs., Ms., Dr., …)
First Name
Last Name
Address
Phone
Title (Mr., Mrs., Ms., Dr., …)
First Name
Last Name
Address
Phone
Sponsor details (who is going to pay for your fees?)
Relationship
First Name
Last Name
Address
Phone
Email
– Please complete all sections and include the fees.

– Places can only be reserved once full fees have been received.

– Please note that registration & administration fees are not refundable.

– Administration and registration fees GBP100.00

Residence Status
Do you need a visa allowing you to stay in the U.K.?
 
If Yes, please give details.
If Other, please explain.
Have you ever been refused a visa to the U.K.
If Yes, please give details.
Health
Do you have any medical condition?
If Yes, please give details.
You can refer to the list below
Visual impairment
Hearing impairment
Disability affecting physical mobility
Other (Asthma, Diabetes, Epilepsy,…)
Emotional or behavioural disorder
Mental illness
Temporary disability after illness or accident
Asperger’s syndrom
Moderate or severe learning difficulties
Dyslexia
Dyscalculia
Other learning difficulties
Have you received any special learning support at school? (eg. Have you had extratime in exams or a statement of educational need?)
If Yes, please give details.