Formulaire d’inscription du Représentant ILH
For the attention of:
Name of Agency
*
Contact Name:
*
Agency e-mail address:
*
Has a deposit / full amount been paid?
Student Details:
Family name:
*
First Name:
*
Sex:
*
Male
Female
Nationality:
Date of Birth:
*
Mobile phone number:
Parent/Guardian's mobile phone number if student under the age of 18:
Profession:
Hobbies and interests:
Allergies / special medical or dietary requirements:
*
Yes
No
Details
*
Would the student accept pets?
*
Yes
No
Details
*
for example: Allergic to cats, doesn't like dogs etc.
Smoker?
*
Yes
No
If 'yes' how many per day?
*
Arrival date:
*
Departure date:
*
Transfer required on arrival?
*
Yes
No
Not Sure
Transfer required on departure?
*
Yes
No
Not Sure
Course Details:
Language:
*
English
French
Italian
Spanish
German
Portuguese
Japanese
Chinese
Romanian
Czech
Norwegian
Swedish
Arabic
Turkish
Destination country:
*
Preferred region or city:
Number of hours tuition per week:
*
15
20
25
30
Type of course: (e.g. Standard, Executive Plus, etc.)
*
Accommodation:
*
Standard
Private Bathroom
Language level:
*
Beginner
Elementary
Low Intermediate
Intermediate
High Intermediate
Advanced
Other information
I accept ILH
terms and conditions
for agents
Yes
Anglais
Français
Italien
Espagnol