Personal Information

Student's Family Name

*

Student's 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 Month - 1 2 3 4 5 6 7 8 9 10 11 12 Year *

Sex

Male Female *

Nationality

*

Mother Tongue

*

Level of English

- Beginner Poor Medium Good *

How long have you been studying English?

- 0 1 2 3 4 5 6 7 8 9 10+ years and - 0 1 2 3 4 5 6 7 8 9 10 11 12 months *

Please give details of any health problems, and any other information you feel we should know.

Student's Contact Details

Street

*

City

*

State/Region

*

Postcode/Zip Code

*

Country

*

Telephone

*

Mobile

Email

Emergency Contact: Name

*

Emergency Contact: Telephone

*

Contact Details for billing

Your Name

*

Telephone

*

Email

*

Fax

Relationship to Student

*

Plus, if different from above:

Street

City

State/Region

Postcode/Zip Code

Country

Course Information

Junior Programme with:

- Homestay - Shared Room Homestay - Single Room Residential Accommodation No Accommodation

Number of weeks

*

Start date (Monday)

- 23 June 2008 30 July 2008 7 July 2008 14 July 2008 21 July 2008 28 July 2008 4 August 2008 11 August 2008 18 August 2008 *

Additional Programme

- None Leisure English Football Leisure English Sailing *

Accommodation

Arrival date

- 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 - June July August - 2008

Leaving date

- 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 - June July August - 2008

Is there any other information that we should know when finding you a family?
e.g. no pets, no children, allergies, food.

Please note:

1. For homestay, it is our policy for junior students to share a twin room with a student of the same sex and similar age but different nationality.  If you wish to have a single room, there will be an extra charge of £10 per week.

2. Please note that residential accommodation is only available from 6 July.

Travel & Insurance

Taxi transfer from the airport to your accommodation (single journey)

- None From Heathrow (£90) From Gatwick (£95) From Stansted (£155) From Central London (£135) *

Do you wish the school to provide insurance cover?

Yes No*

Payment Details

Pay enrolment fee (£60)

- By bank transfer By cheque By credit card (2% surcharge) By debit card *

Pay balance

- By bank transfer By cheque By credit card (2% surcharge) By debit card Two weeks before arrival *

Bank transfer:   The school's bank details are as follows.

Pay:  Lewis Schools Ltd

Bank's address:  Lloyds TSB Bank, 19-21 High Street, Southampton SO14 2SE, UK

Account number: 0064804

Bank Sort code: 30-97-80

BIC: LOYDGB21032

IBAN: GB88 LOYD 3097 8000 0648 04

Please use the student’s full name as the bank reference for us. You must pay all bank charges. Please check with your bank when you make the transfer. You will be asked to settle all unpaid bank charges a minimum of two weeks before arrival.

Cheques:  Payable to Lewis Schools Ltd

Credit Card:  There is a 2% surcharge on all payments by credit card.  The Lewis School does not have a secure Internet connection.  Please print our Credit / Debit Card Payment form and send it to us by POST or FAX.

Debit card:  There is no surcharge on payments by debit card.  The Lewis School does not have a secure Internet connection.  Please print our Credit / Debit Card Payment form and send it to us by POST or FAX

How did you hear about the Lewis School?

- Lewis School Website Agent British Council Embassy Friend or relative in Southampton Guide book I am an ex-student of the Lewis School Recommendation by an ex-student University of Southampton Southampton Solent University Other website - EducationUK Other website - English in Britain Other website - Okey-Dokey Other website - Orbislingua Yellow Pages *

Before you submit

I have read and agree to the

terms and conditions of enrolment. *

As soon as we receive your booking form we will confirm your place and send you an enrolment letter and an invoice.