APPLY ONLINE

Student Information
All items marked with * are required.

First Name*:
Last Name*:
Date of Birth*:
Gender*: MF
Email*:
Tel*:
Fax:
Home Address*:
City*
State/Province
Zip/Postal Code*:
Country* :


Do you have any special requirements we should be made aware of?

Dietary*: Yes No
If yes, please give details:
Medical*: Yes No
If yes, please give details:



Parent Information

First Name*:
Last Name*:
Gender*: MF
Relationship to student*:
Email*:
Use same contact info as above (no need to re-type if checked)
Tel (Home)*:
Tel (Work):
Fax:
Home Address*:
City*
State/Province
Zip/Postal Code*:
Country* :



School Information (Optional)

Present School:
Current Grade:
Address:
City:
State/Province:
Zip:
Tel:
Name of Principal/Director:


Programme Information


In case your first choice course is full, please provide an alternative second choice course as well.

The 2010 July Programme is now full.

Courses for August marked in blue.

1st Choice:
2nd Choice:




Insurance (please tick one)*

I will purchase the recommended travel insurance from Travel Insurance Center:
I already have comprehensive travel insurance and will forward a copy of the policy within 10 days of this application:



Customize Your Programme
Community Outreach (Extra 10 hours community service) - £150: Yes No
Young Leader Programme - £395Yes No
University Advance - £250 per university: Yes No
If yes please specify a university:
Single room upgrade (£395): Yes No
If no, I would like to room with (optional):


If a friend recommended you, please enter their details here:
Name:
Email:

Where did you hear about us?
Friend
Google
Facebook
Other -




Payment


Payment Method:
I have read the Terms & Conditions and Rules & Regulations (*required)