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TCU
Guadeloupe-student-registration-form
STUDENT APPLICATION FORM
Guadeloupe: 16th to 23rd 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 Guadeloupe 2017 programme is TTD10,500. 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 $3,000.00
31st March 2017: Final payment of $3,500.00
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
Male
Female
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T-Shirt Size
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S
M
L
XL
2XL
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School
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Form
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E-mail
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Tel (Home)
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Mobile
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Passport Number
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Passport Cpoy
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Passport Expiry Date
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2. Guardian 1
Name
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Relationship
(*)
Please type your surname
Tel
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Mobile
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E-mail
(*)
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Occupation
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Employer
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3. Guardian 2
Name
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Relationship
(*)
Please type your surname
Tel
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Mobile
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E-mail
(*)
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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)
Select
Yes
No
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Details
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Do you have any food allergies?
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Yes
No
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Details
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Do you have any special dietary requirements?
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Yes
No
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Details
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6. Medical Information
Asthma
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Yes
No
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Details
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Bronchitis
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Yes
No
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Details
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Heart Condition
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Yes
No
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Details
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Fits, fainting or Blackouts
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Yes
No
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Details
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Severe Headaches
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Yes
No
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Details
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Diabetes
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Yes
No
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Details
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Allergies to any known drugs
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Yes
No
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Details
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Any other allergies (eg. Material)
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Yes
No
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Travel sickness
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No
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Details
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Back, knee or other joint problems
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No
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Details
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Any injury, break or sprain
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Yes
No
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Details
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Other illness, medical condition or disability
Select
Yes
No
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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?
Select
Yes
No
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Have you been given specific medical advice to follow in emergencies?
Select
Yes
No
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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
(*)
I hereby declare that the statements made by me in answer to the foregoing questions are true and complete to the best of my knowledge and belief.
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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
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Declaration
I agree to allow my child to participate in water activities and/or swim during the programme.
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Signature of Parent/Guardian (if Student is under 18):
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OR
Signature of Student (if 18 or over)
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Consent to photograph film or videotape a student
Student Name
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School Name
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Declaration
I hereby consent to the participation in interviews, the use of quotes, and the taking of photographs, movies or video tapes of the Student named above. I also grant the right to edit, use, and reuse said products in print, on the internet, and all other forms of media for purposes related to the project.
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Signature of Parent/Guardian (if Student is under 18):
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OR
Signature of Student (if 18 or over)
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< Prev
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Consent to access WIFI
Student Name
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School Name
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Declaration
I agree to allow my child to access WIFI during the programme.
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Signature of Parent/Guardian (if Student is under 18):
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OR
Signature of Student (if 18 or over)
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