Booking

Please read the terms and conditions before completing this booking form.

Personal details
Family name (as on your passport)
First name (as on your passport)
Address
Country
Telephone number (home)
Parents' daytime tel. number
Parents' mobile tel. number

Student's email address
Parents' email address
Sex	female male
Nationality
Date of birth (day.month.year)
Main language spoken
Course details
Course town
Course start date (day.month.year)
Course end date (day.month.year)
Accommodation
For homestay courses only:
Room	double room included in price, sharing with a student of a different nationality
	single room (£30 extra per week)
If you are travelling with a friend and would like to share a room with your friend, please write the friend's name here....

If you have any special wishes regarding your accommodation (eg. allergies, vegetarian, special dietary needs, etc.), please give details here ....

If you have or have recently had any medical condition (physical or mental) which might affect your studies or which your host family should know about, please give details here ...

Your School
How many years have you been learning English?
Full name of your school
Full address of your school
Name of your English teacher	Mrs. Mr.

Payment
How do you want to pay for your course?	credit card
(We will send details with your booking confirmation)	bank transfer
	traveller's cheque

The following must be completed by a parent or guardian
First name and family name of parent or guardian
I hereby confirm that I have read the terms and conditions

Cicero Languages International