Student Name *

First Name

Last Name

Student's Phone

Country

(###)

###

####

Student Date of Birth *

MM

DD

YYYY

Student's Sex *

Male

Female

Parent Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent Phone *

Country

(###)

###

####

Emergency Contact

Country

(###)

###

####

Type of Accommodation *

Full-board with host family

No accommodation required

Arrival Date *

MM

DD

YYYY

Arrival Flight Time

Hour

Minute

Second

AM PM

Departure Date *

MM

DD

YYYY

Departure Flight Time

Hour

Minute

Second

AM PM

Confirmation *

I have read the terms and conditions (link below) and would like to book a place on the selected Language and Leisure course. By clicking 'submit' below I agree to proceed to the payment stage and pay a non-refundable deposit of €200. (An invoice will also be sent to you with details of how to pay the full course fees.)