EJO English Language Courses

* means that item must be filled in

Course *

Arrival Date *

Departure Date *

Students Details:

Title:

First Name(s): *

Lastname: *

Email address:*

Phone:*

Group: (if applicable)

Date of Birth *

Emergency Contact Details (Next of Kin):

Firstname:*

Lastname:*

Address:*

Phone No:*

Email:*

Medical Insurance:

Is the student covered by medical insurance?

Yes No

Does he/she have any of the following?

E128 E112 European Health Insurance Card Other

Medical Conditions:

Does the student suffer from any of the following? If YES, please give details below:

Asthma/bronchitis

Yes No

Fits, fainting, blackouts

Yes No

Allergies to medication

Yes No

Other allergies e.g food, animals

Yes No

Heart condition

Yes No

Diabetes

Yes No

Migraine/severe headaches

Yes No

Travel sickness

Yes No

Other illness/disability

Yes No

Regular medication

Yes No

Details of Medical Conditions:

If it is considered necessary, do you consent to mild pain killers (e.g Paracetamol) being administered?

Yes No

Has the student been vaccinated against tetanus in the last 10 years?

Yes No

Has the student had surgery/specific medical treatment of any kind recently? (If the answer is YES, please give details below)

Yes No

Surgery / Medical Treatment Details:

Rules for students

English law protects young people under the age of 18 very carefully and EJO has the following rules in place for its students. Please read these very carefully and sign the declaration below:

Students under thirteen years may not go out unaccompanied at anytime
Students of thirteen to seventeen years may go out unaccompanied but must be home by 10.00pm. The only exception is the evening programmed activity. Homestay hosts collect their students at the end of the evening activity.
Students aged seventeen must be back home by 11.00pm
Students who are eighteen or over may go out as they wish but we encourage them not to stay out late and obviously also to respect the wishes of their homestay hosts.
Students are not permitted to spend the night away from their host‘s home
Students on residential courses may not leave the campus unless accompanied by a responsible adult at anytime.
All students will participate fully in the programmed activities, excursions and English lessons
During the times when unsupervised by EJO staff - this could include travelling to and from the course each day, going out at break or lunch time or in the evening or Sunday - students will adhere to EJO safety guidelines

Declaration:

I confirm that I am the parent/guardian of the above-named student. He/she is in good health and I consent to him/her taking part in the activities and excursions of the course and centre according to the rules above. In the event of illness or accident, I consent to any necessary medical treatment, including the use of anaesthetics.*

Relationship to Student:

Get In Touch

EJO English Language Programmes Medical Declaration and Parental Consent Form

Thank you for enrolling in an EJO International Summer Programme. Please now fill out the Necessary Medical Declaration and Parental Consent Form

We will contact you shortly to confirm your registration. In the meantime, please complete and submit the form below. It is ESSENTIAL for us to have this information in case of emergency. Any queries please contact us on +44 1428 751549 or email at info@ejo.co.uk

* means that item must be filled in

Students Details:

Emergency Contact Details (Next of Kin):

Medical Insurance:

Is the student covered by medical insurance?

Does he/she have any of the following?

Medical Conditions:

Asthma/bronchitis

Fits, fainting, blackouts

Allergies to medication

Other allergies e.g food, animals

Heart condition

Diabetes

Migraine/severe headaches

Travel sickness

Other illness/disability

Regular medication

If it is considered necessary, do you consent to mild pain killers (e.g Paracetamol) being administered?

Has the student been vaccinated against tetanus in the last 10 years?

Has the student had surgery/specific medical treatment of any kind recently? (If the answer is YES, please give details below)

Rules for students

Declaration: