Family Name  
First Name     

How would you like to communicate?
email?          fax           post

Home address (in your country) or contact adress (if different)
Address       
City              
Country        
Post/Zip code
Telephone    
Fax              
email           

Please give the details of who to contact in an emergency
Name          
Telephone   
Fax             
email          
Relationship to you

Personal Information

Sex:             male              female
Date of birth (dd/mm/yyyy) 
Occupation
First language
Nationality    
Have you got any medical condition which the School needs to know about?

Why do you want to study English?

How did you hear about the Eckersley Oxford


Course Information

Name of the course
Hours per week:   15           21
Start date (dd/mm/yyyy)      Finish date (dd/mm/yyyy)
Number of weeks   
Are you a beginner in English?    Yes      No
If you would like to take an exam please indicate which one:
FCE     CAE     IELTS      Other

Passport

Passport number
Visa type
Date of Visa expiry (dd/mm/yyyy)

Flight Details

If you have booked your flight please write the details here:
Airport          Terminal  
Date    Arrival time    Flight number
Date     Departure time    Flight number

Airport Transfer

Do you want the School to arrange taxi transfer from the airport?
Yes      No

Accommodation

If you are studying for at least 15 hours a week and would like the School to arrange accommodation for you, please complete this part of the form.

Arrival date (Sunday - dd/mm/yyyy):

Departure date (Saturday - dd/mm/yyyy):

Do you have any allergies or dietary requirements?


What are your hobbies or interests?


Please give any other information that could be useful to the Accommodation Manager:


Homestay

Help us to choose the right family for you by answering the following questions: We will try to meet your requirements.

Do you smoke? Yes No

If you don´t smoke, would you accept a family where people smoke? Yes No

Would you accept a family with young children? Yes No

Would you accept a family with a pet (dog, cat, bird, etc.) Yes No


Dover House (Residence)

Single room Shared room

Please note: Dover House is a non-smoking house

Payment. We will only arrange accommodation when we have received the deposit and registration fee. The accommodation fee must be paid in full to the School not later than 7 days before the start of your course.

Your accommodation will be reserved from the Sunday before your course begins until the Saturday after it ends. You will be charged for complete weeks, but your last week will be 6 nights.

How to apply for a course

Send this application form together with a Registration Fee (65 GBP) and a Deposit (200 GBP) to confirm your enrolment and to book your accommodation. We will send you a Certificate of Enrolment and a statement of the fees to be paid. If we cannot accept you for the course you want to do, we will return your deposit and registration fee.

Please choose a method of payment. Cheque, bank transfer or credit card.

Please make sure that your name appears on the transfer document. Please pay all bank charges. If charges are deducted in Britain, we will ask you to pay them when you arrive.

Please note that this is not a secure site. You may prefer to give us your card details on the phone, via fax or email.

Credit card Visa Mastercard JCB

There will be a 3% surcharge for credit card payments.

Name of card holder:

Expiry date:

Card number:

Debit from my account 265 GBP Registration Fee and Deposit.

Debit from my account the balance of tuition and accommodation fees 7 days before the start of my course (We will confirm the amount when we receive this form).

Person or organisation paying the fees:

Myself Parent Other:

I accept the Terms and Conditions. I agree to pay the rest of the fees not later than 7 days before the start of my course (For students under 18 years old, a parent or legal guardian should sign).

Please tick this box if you do not wish your photographs, taken in connection with your course, to be used for promotional purposes (i.e. website, presentations, etc.)