Registration Form Chose a course Course ONE (July): Course TWO (August): Student Details Surname: First Name: Date of birth(DD/MM/yyyy): 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 01 02 03 04 05 06 07 08 09 10 11 12 / 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Age (When Arrived): Gender: Male Female Number of Brothers: Age: Number of sisters: Age: First parent email address: Confirm first email address: Second parent email address: Confirm second e-mail address: Email address for placement test: The link for the placement test will be sent to this email ONLY. In the case of siblings, please use a different email address for each child Telephone Numbers (to include country code) Mother: Father: Student: Contact details (in case of emergency): Medical Authorization We ask you to review the attached medical authorization document for your child. If you agree to provide authorization, please complete the form and upload the requested files through the provided platform. Download Italian Medical Authorization Download Spanish Medical Authorization Download French Medical Authorization Download German Medical Authorization Yes No Upload Medical Files (up to 5 files): Only PDF, image, and Word files are allowed. Invoice Information Name to be included on invoice Address: City: ZIP code: Country: AFGHANISTAN ÅLAND ISLANDS ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA AND HERZEGOVINA BOTSWANA BOUVET ISLAND BRAZIL BRITISH INDIAN OCEAN TERRITORY BRUNEI DARUSSALAM BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA CHRISTMAS ISLAND COCOS (KEELING) ISLANDS COLOMBIA COMOROS CONGO CONGO, THE DEMOCRATIC REPUBLIC OF THE COOK ISLANDS COSTA RICA CôTE D’IVOIRE CROATIA CUBA CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS (MALVINAS) FAROE ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA FRENCH SOUTHERN TERRITORIES GABON GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUERNSEY GUINEA GUINEA-BISSAU GUYANA HAITI HEARD ISLAND AND MCDONALD ISLANDS HOLY SEE (VATICAN CITY STATE) HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN, ISLAMIC REPUBLIC OF IRAQ IRELAND ISLE OF MAN ISRAEL ITALY JAMAICA JAPAN JERSEY JORDAN KAZAKHSTAN KENYA KIRIBATI KOREA, DEMOCRATIC PEOPLE’S REPUBLIC OF KOREA, REPUBLIC OF KUWAIT KYRGYZSTAN LAO PEOPLE’S DEMOCRATIC REPUBLIC LATVIA LEBANON LESOTHO LIBERIA LIBYAN ARAB JAMAHIRIYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAO MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MEXICO MICRONESIA, FEDERATED STATES OF MOLDOVA, REPUBLIC OF MONACO MONGOLIA MONTENEGRO MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NETHERLANDS ANTILLES NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PALESTINIAN TERRITORY, OCCUPIED PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES PITCAIRN POLAND PORTUGAL PUERTO RICO QATAR RéUNION ROMANIA RUSSIAN FEDERATION RWANDA SAINT BARTHéLEMY SAINT HELENA, ASCENSION AND TRISTAN DA CUNHA SAINT KITTS AND NEVIS SAINT LUCIA SAINT MARTIN (FRENCH PART) SAINT PIERRE AND MIQUELON SAINT VINCENT AND THE GRENADINES SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SENEGAL SERBIA SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS SPAIN SRI LANKA SUDAN SURINAME SVALBARD AND JAN MAYEN SWAZILAND SWEDEN SWITZERLAND SYRIAN ARAB REPUBLIC TAIWAN, PROVINCE OF CHINA TAJIKISTAN TANZANIA, UNITED REPUBLIC OF THAILAND TIMOR-LESTE TOGO TOKELAU TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED KINGDOM UNITED STATES UNITED STATES MINOR OUTLYING ISLANDS URUGUAY UZBEKISTAN VANUATU VENEZUELA, BOLIVARIAN REPUBLIC OF VIET NAM VIRGIN ISLANDS, BRITISH VIRGIN ISLANDS, U.S. WALLIS AND FUTUNA WESTERN SAHARA YEMEN ZAMBIA ZIMBABWE Email address: If you require other information on the invoice for example Codice Fiscale, Numero de Identifification Fiscal please fill in the following Parent CF / NIF Student CF / NIF Flight details: Arrival Arrival Date (DD/MM/YYYY): Arrival Airport: DUBLIN Airline: AERLINGUS RYANAIR IBERIA AIR FRANCE LUFTHANSA SAS GROUP ALITALIA EASYJET EUROWINGS BRITISH AIRWAYS KLM VUELING AIRWAYS OTHER Flight Number Arrival Time 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 : 00 05 10 15 20 25 30 35 40 45 50 55 Flight details: Departure Departure date (DD/MM/YYYY): Departure Airport DUBLIN Airline: AERLINGUS RYANAIR IBERIA AIR FRANCE LUFTHANSA SAS GROUP ALITALIA EASYJET EUROWINGS BRITISH AIRWAYS KLM VUELING AIRWAYS Flight Number Departure Time 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 : 00 05 10 15 20 25 30 35 40 45 50 55 Previous english examinations taken: KET: PET: First cerificate (FCE): CAE: CPE: BEC: TRINITY: IELTS: TOEIC: Results: Health information Health problems (e.g. diabetes, allergies, etc): NO YES Learning difficulties: NONE DYSGRAPHIA DYSLEXIA NON VERBAL LEARNING DISABILITIES ADHD OTHER If other, describe the problem: Mental health difficulties: NONE ANXIETY AUTISM SPECTRUM DISORDER (ASD) EATING DISORDER OTHER If other, describe the problem: Blood group (if available): General information Father’s Surname: Father’s Name: Profession: Mother’s Surname: Mother’s Name: Profession: Student personal information Is this your first stay away from your family? Yes No Number of stays abroad: In which countries? Favourite Hobbies and sport: Do you play an instrument? Please describe your personality Do you have any pets at home? What are your favourite foods? What food do you not like? Is this your first time participating in the Claddagh school of English? Yes No Do you wish to return to the same host family if available? Yes No Do you have friends participating in the Claddagh school of English this year? Yes No If Yes, name of other students: Upload your photo: Acceptance Do you confirm the data and the conditions specified above? Yes No Form of consent to tratment of personal data and images of the student (not required) I, the undersigned consent (on behalf of my daughter/son) to the processing of personal data and images, produced during the course which MAY be posted on the website/or facebook pages of the school I consent I do not consent School rules I HAVE READ AND DISCUSSED THE SCHOOL RULES WITH MY CHILD. Agree Disagree Terms and Conditions I HAVE READ AND I AGREE THE TERMS AND CONDITIONS – EN – IT – ES Agree Disagree Captcha code Change Code When sending the deposit of 200 euro please indicate the name of the child to whom it refers and the invoice number and email the receipt to Mary Magee at halcyon141@gmail.com Medical insurance: every student must bring their national health card Four week visit to Ireland to experience Irish life, learning English and having fun APPLY TODAY
