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Cuba Student Application Form

STUDENT APPLICATION FORM
Cuba: 07th to 14th April 2017

Thank you for your interest in our progammes. Please note that Reperio has a rolling admissions policy. This means that it is important to apply early, as some programmes fill prior to their stated deadlines.

The total cost of the Cuba 2017 programme is TTD12,000. This price includes:
  • Airfare
  • Accommodation
  • Transport and/or tours
  • Insurance
  • All meals
Please note that on admission to the programme, payments are refundable of up to 50% until 28th February 2017, after which there will be no refunds.

Application Materials
Your application will be reviewed on receipt of the following:
  • Completed application forms
  • Initial downpayment
  • Copy of passport

You can hand in your application at school or e-mail to: info@reperio-caribbean.com

Important Deadlines
31st January 2017: First payment of $4,000.00
28th February 2017: Second payment of $4,000.00
31st March 2017: Final payment of $4,000.00

Payment can be sent by cheque (payable to TT Shuttle Ltd.)
Payments may alternatively be deposited to the following bank account:
TT Shuttle Ltd
First Citizens Bank account #: 1744377
Trinidad & Tobago (Please be mindful of including applicant’s name on deposit slip.)
1. Your details
First name(*)
Please type your first name.

Surname(*)
Please type your surname

Address
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Date of birth

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Sex
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T-Shirt Size
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School
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Form
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E-mail(*)
Invalid email address.

Tel (Home)

Mobile

Passport Number
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Passport Cpoy
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Passport Expiry Date

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2. Guardian 1
Name(*)
Please type your first name.

Relationship(*)
Please type your surname

Tel
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Mobile
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E-mail(*)
Invalid email address.

Occupation
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Employer
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3. Guardian 2
Name(*)
Please type your first name.

Relationship(*)
Please type your surname

Tel
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Mobile
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E-mail(*)
Invalid email address.

Occupation
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Employer
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4. Your doctor’s details
GP/Surgery
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Name
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Telephone
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Address
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5. Diet
Are you vegetarian or vegan? (please specify)
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Details
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Do you have any food allergies?
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Details
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Do you have any special dietary requirements?
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Details
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6. Medical Information
Asthma
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Details
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Bronchitis
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Details
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Heart Condition
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Details
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Fits, fainting or Blackouts
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Details
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Severe Headaches
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Details
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Diabetes
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Details
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Allergies to any known drugs
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Details
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Any other allergies (eg. Material)
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Details
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Travel sickness
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Details
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Back, knee or other joint problems
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Details
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Any injury, break or sprain
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Details
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Other illness, medical condition or disability
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Details
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7. Further medical details
Are you receiving medical or surgical treatment of any kind from your doctor or hospital?
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Have you been given specific medical advice to follow in emergencies?
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If the answer to either of these questions is YES, please give details here (including dosage of any medicines/tablets)
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Declaration(*)
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Signature
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Signature of Guardian
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Consent to participate in water activities
Student Name
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School Name
Invalid Input

Declaration
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Signature of Parent/Guardian (if Student is under 18):
Invalid Input

OR
Signature of Student (if 18 or over)
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Consent to photograph film or videotape a student
Student Name
Invalid Input

School Name
Invalid Input

Declaration
Invalid Input

Signature of Parent/Guardian (if Student is under 18):
Invalid Input

OR
Signature of Student (if 18 or over)
Invalid Input

 
Consent to access WIFI
Student Name
Invalid Input

School Name
Invalid Input

Declaration
Invalid Input

Signature of Parent/Guardian (if Student is under 18):
Invalid Input

OR
Signature of Student (if 18 or over)
Invalid Input

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