Lewis School of English

Family Name *

First Name *

Date of Birth - Day - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 *

Date of Birth - Month - January February March April May June July August September October November December *

Date of Birth - Year - 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 *

Gender Male Female *

Nationality *

First Language *

Level of English *

Address Line 1 *

Address Line 2 *

Address Line 3

Postcode *

Country *

Telephone *

Mobile

Fax

Email *

Do you need a taxi transfer on arrival? Yes No *

Date ...

Flight number

Flying from

To - London Gatwick LGW London Luton LTN London Stansted STD London St Pancras QQS Bournemouth BOH Birmingham BHX Bristol BRS Southampton Airport SOU

Do you need a transfer on departure? Yes No *

Date ...

Flight number

Flying from - London Gatwick LGW London Luton LTN London Stansted STD London St Pancras QQS Bournemouth BOH Birmingham BHX Bristol BRS Southampton Airport SOU

To

Does the student suffer from any physical or mental health problem? No Yes *

if yes, please give details

Does the student suffer from any allergies? No Yes *

if yes, please give details

Is the student currently taking any medications? No Yes *

if yes, please give details

Emergency Contact (Name and Mobile Telephone) *

Relationship to Student *

Programme Chosen Select Your Course Winter Junior Programme - Southampton - Homestay Accommodation Winter Junior Programme - Southampton - No Accommodation Southampton (Summer Centre) - Homestay Accommodation Southampton (Summer Centre) - Residential En-suite Accommodation Southampton (Summer Centre) - No Accommodation Reading - Residential En-suite Accommodation Reading - No Accommodation London Harrow - Residential En-suite Accommodation London Harrow - No Accommodation New Forest - Homestay Accommodation New Forest - No Accommodation Northern Cyprus - Residential Shared En-suite Accommodation *

Number of Weeks *

Arrival Date ... *

Departure date ...

Pay enrolment fee (£75) - Online payment using PaytoStudy By bank transfer By credit card (2% surcharge) By debit card *

Pay balance - Online payment using PaytoStudy By bank transfer By credit card (2% surcharge) By debit card *

Name *

Address Line 1 *

Address Line 2

Address Line 3

Postcode *

Country *

Telephone

Fax

Email

I have read and agree to the terms and conditions of enrolment. *

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