Application & Consent form Juniors 2022 BANGO R COURSES JUNIOR SUMMER PROGRAMME 2022 Duration (weeks) Start date (DD/MM/YY) End date (DD/MM/YY) Junior Summer Programme - Bangor PERSONAL INFORMATION ABOUT THE STUDENT First name*: Family name*: Date of birth (DD/MM/YY): Age: Country of birth: Nationality: First language: Passport number: Gender: Male Female Non-binary Home address: Country: Zip/postcode: How did you hear about us? *Please provide first and family names as they appear on the passport CONTACT INFORMATION Telephone (mobile): Email: Smartphone apps: WhatsApp – ID: Line – ID: WeChat – ID: KakaoTalk – ID: Viber – ID: Telegram – ID: EMERGENCY CONTACT DETAILS #1 (person with legal responsibility for the student) Name: Relation to student: Telephone: Level of English: Email: Low Medium High EMERGENCY CONTACT DETAILS #2 (person with legal responsibility for the student) Name: Relation to student: Telephone: Level of English: Email: Low Medium High SPECIAL REQUESTS Special dietary requirements: Halal Vegetarian Please give details: Gluten free Special religious requests*: YES NO If yes, please provide more information: Lactose free Other * Please inform us if you are a practising Buddhist, Christian, Jew, Muslim or any other religion so that we can be aware during your stay. ARRIVAL & DEPARTURE Do you require a transfer from the airport when you arrive?* YES NO If NO, please give details of the person who will travel to the centre with the student: Arrival airport: Airline name: Flight number: Date of arrival: Time of arrival: Arrival airport: Will you arrange with the airline for the student to travel as an unaccompanied minor?** YES NO Page 1 Application & Consent form Juniors 2022 Do you require a transfer to the airport at the end of your course?* YES NO If NO, please give details of the person who will travel from the accommodation with the student: Departure airport: Airline name: Flight number: Date of departure: Time of departure: Departure airport: Will you arrange with the airline for the student to travel as an unaccompanied minor?** YES NO * All students under 18 must book a return transfer unless confirmation that a private transfer with a responsible adult has been arranged and is sent to Celtic. ** For students travelling alone, an unaccompanied minor fee is compulsory for departure. The driver will accompany the student to check-in and handover at security. Upon departure, all UMs will be handed to the relevant airline staff after check-in and, in most cases, the Celtic named person will wait with the student until airline staff take the student to the aircraft. MEDICAL DETAILS STUDENT’S DOCTOR/CONSULTANT IN HOME COUNTRY First name*: Family name*: Address: Country: Zip/postcode: Telephone: Email: I confirm I have booked private travel & medical insurance for the student which is valid during the dates of the programme. MEDICAL CONDITIONS Type of medical condition YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO Please give details Asthma / bronchitis Heart condition Fits / fainting / blackouts Severe headaches / migraine Eczema / skin condition Hay fever Diabetes Any known allergies to medication (e.g. penicillin) Other allergies (e.g. nut, lactose, gluten, chlorine, Velcro, etc.) Travel sickness Convulsions / epilepsy Regular hospital treatment Dyslexia Autism Asperger Learning difficulties or psychological condition ADHD Mental health problems (e.g. depression) Anxiety Anorexia Bulimia Page 2 Application & Consent form Juniors 2022 YES NO YES NO YES NO VACCINATIONS YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO OCD – Obsessive Compulsive Disorder Acrophobia, Claustrophobia or Nyctophobia Other physical or mental health condition Diphtheria Date (DD/MM/YY): Tetanus Date (DD/MM/YY): Polio Date (DD/MM/YY): Measles Date (DD/MM/YY): Mumps Date (DD/MM/YY): Rubella Date (DD/MM/YY): Hepatitis A Date (DD/MM/YY): Hepatitis B Date (DD/MM/YY): Hepatitis C Date (DD/MM/YY): Meningitis Date (DD/MM/YY): Covid-19 Date (DD/MM/YY): ADDITIONAL INFORMATION Does the student take any regular medication/injections which he/she will bring with him/her? YES NO If yes, please identify the medication, reason for usage, dosage and frequency. Please also state how it is advised that we store the stude

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