Course* Adult Total Immersion Adult Just Study

No of weeks* select weeks 1 2 3 4 5 6 7 8

Arrival date* select arrival date 29/06/2015 06/07/2015 13/07/2015 20/07/2015 27/07/2015 03/08/2015 10/08/2015 17/08/2015 I want to start on another date

If you cannot arrive on one of the starting dates in the box, tell us which date you want to arrive on.

I want to start on…

I will take the bus to Dundalk.*   YES NO

I would like a private airport transfer.*   YES NO

Please fill in this section carefully so that we have all your details. *obligatory

STUDENT DETAILS

Name*

Family name*

Address:*

Date of birth*

Mobile phone number*

Home phone number

Email Address*

Confirm Email*

Nationality*

Mother tongue(s)*

Occupation*

Next of kin name*

Next of kin mobile*

How did you hear about The Language Place?* friend my language school internet agent other (please tell us)

What is your current level of English?* (If you are not sure, you can test your English here) A1.1 Beginner A1.2 Elementary A2.1 Pre-Intermediate A2.2 KET B1.1 Intermediate B1.2 PET B2.1 Upper-Intermediate B2.2 FCE C1.1 Advanced C1.2 CAE

Tell us about your previous English studies here*

Tell us why you want to improve your English here*

Tell us what you would really like to do in your intensive English course here*

Tell us what you would prefer* select accommodation host person/family self-catering apartment I don’t need accommodation

If you want to share a host family or apartment with a friend, tell us your friend’s name

If you choose a host person/family, please complete this section.

Do you have any physical disabilities or special needs we need to tell your host family about?*   YES NO
If YES, give details here.

Do you have allergies?*   YES NO
If YES, give details here.

Are there any foods you can’t eat or really don’t like eating?*   YES NO
If YES, give details here.

Is it ok if your host family has pets?*   YES NO
If NO, give details here.

Do you have a European Health Insurance Card?*  YES NO

Mark the activities you are interested in.*

football   television   reading   basketball   cinema   travelling   tennis  
theatre   water sports   cycling   music   video games   swimming   IT  
photography   golf   clubbing   horse-riding   walking   dancing   art

Please give details of any other hobbies and interests you have here:

If there is anything else you want to tell us, write it here

Read more about the adult total immersion course in English

Read more about the adult total immersion course in Spanish

Read more about the adult total immersion course in French

Read more about the adult total immersion course in German

Read more about the adult total immersion course in Italian

I have read the terms and conditions of the adult total immersion course*