EmailMe Form - Registration Form for School Groups

Name of Student *

First Last

Date of Birth *

Gender *

Male

Female

Home Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Home Telephone *

Mobile Number Student *

Father's Full Name *

Father's Mobile Number *

Father's E-mail *

Mother's Full Name *

Mother's Mobile Number *

Mother's E-mail *

Health and Medical Information

Does your child suffer from any disability? *

Yes

No

If yes, please detail.

Does your child follow any special diets? *

Yes

No

If yes, please detail.

Does your child have any allergies? *

Yes

No

If yes, please detail.

Is your child currently receiving any medical treatment at present? *

Yes

No

If yes, please detail.

Does your child have a valid E111 card? *

Yes

No

Details about the Student

Can your child swim? *

Yes

No

What are their favourite sports, hobbies and interests? *

English Study Programme

I wish to enrol at:

Which school does your son/daughter attend? *

Requested Start Date *

Requested departure date *

Consents

Present Level of English *

Beginner

Improver

Intermediate

Advanced

I have read and accept the Terms and Conditions of Antler Languages Ltd and also give my consent as follows (see below):

Click here to read our T&C's *

Agree

Photographic Consent *

Agree

Parental Authorisation *

Agree

Name of Parent giving Consent *

First Last

Upload Photo of Passport *

Please let us know if we can contact you for marketing purpose by ticking YES *

Yes please contact me

No