2012 Junior Application Form by 0N4nG1Kh


									                               IH Dublin Junior Application Form 2012

Family Name:__________________________________ ___First Name:________________________________________

Country:______________________ Post Code:________________ Date of Birth:_______________________________

Mobile Telephone:_____________________________ E-mail:_______________________________________________

Nationality:__________________ First Language:________________ Sex:______

Parent Guardian Name:_____________________________________Parent/Guardian Phone:______________________

Current level of English: Very good  Good  Fair None  Did you attend a course at IH Dublin before? Yes  No 
Are you booking your course through an agent? Yes  No  If yes, please provide name: ____________________
Where did you hear about our school?__________________________________________________________________

COURSE DETAILS – Please select a course

I wish to book Junior Summer Programme at Sutton Park School – Homestay Accommodation      
I wish to book Junior Summer Programme at Deer Park Resort – Residential Accommodation     
COURSE DETAILS – please select ahosted at University College Cork – Homestay Accommodation 
I wish to book Junior Summer Programme
I wish to book Junior Summer Programme hosted at University College Cork – UCC Campus Accommodation 
Start Date (dd/mm/yy): ____________________ Number of weeks:_____________


Arrival Date (dd/mm/yy): ____________________ Departure Date:_______________________
Do you have any specific dietary requirements? Yes  No  Details:____________________________________________
Do you have any allergies or health problems? Yes  No  Details:____________________________________________
Do you take any medication?                    Yes  No  Details:____________________________________________


All junior students must book arrival and departure airport transfers, unless accompanied by an adult/guardian.
If you have already booked your flight, please provide details here. Otherwise, please send us with your flight details at least 2
weeks before arrival.
Name of Arrival Airport:_______________________ Name of Departure Airport: ___________________________________
Arrival Date (dd/mm/yy):_______________________ Arrival Flight Number:________________ Arrival Time:_____________
Departure Date (dd/mm/yy):____________________ Departure Flight Number:_____________ Departure Time:__________
I will travel with an adult/guardian from and to the airport and I do not need transfers 
Name of Adult/Guardian:_______________________________________________ Arrival Time:__________________________


I will pay by: Bank Transfer  Credit Card 

Credit Card Payments: Visa  Mastercard  Name of Card Holder:__________________________________________
Card Number:    _ _ _ _ / _ _ _ _ / _ _ _ _ / _ _ _ _ Card Expiry Date (mm/yy):________________CVV Number: _ _ _
I hereby authorise IH Dublin to debit Euro _____________ from the above credit card.

Card holder signature:______________________________________________________
                                                                                                       AGENT STAMP

I have read the terms & conditions and agree to abide by them.
Signed:_______________________________________________ Date:____________________________

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