House name/number: Street :

Town: Postcode:

Country: Emai l :

Telephone: Mobi le :

WHO CAN WE CONTACT IN AN EMERGENCY?

Name: Relat ion to student:

Telephone: Home: Work:

Mobi le : Emai l : � �

HOW DID YOU HEAR ABOUT INSPIRE?

Family Fr iend Agent Teacher Internet

Other - Please give detai ls

Travelux Limited,9/F, So Hong Commercial Building,

41-47 Jervois Street, Sheung Wan, Hong KongTel: +852 2526 6163 Email: info@travelux.hk

REGISTRATION FORMST. ANNE'S COLLEGE, OXFORD FOR 16-19 YEAR OLDS Please write in CAPITALS

PERSONAL DETAILS

Family name:

First name(s):

Sex: Male Female

Date of Birth: DD/MM/YYYY

Age at start of course:

Nationality:

Mother Tongue:

Passport number and expiry date

HOME ADDRESS (all correspondence will be sent here)

MEDICAL & DIETARY INFORMATION

Do you have a medical condit ion or disabi l i ty? : Yes No

Do you have any al lergies (e.g . food stuff , medicines or � �animals)? : Yes No

Do you have any specia l dietary requirements? : Yes No

I f you answered ‘Yes’ to any of these quest ions please give detai ls :

COURSE DATES:

21 Jul 18 – 3 Aug 18

PERMISSIONS

Medical Permission: I g ive permiss ion in an emergency, for a member of Inspire staf f to authorise medical treatment and/or anaesthetic for my chi ld.

Yes No

Activities Permission: I g ive permiss ion for my chi ld to take part in al l act iv it ies associated with Inspire.

Yes No

Photographs Permission: I g ive permiss ion for photographs of my chi ld to be used in marketing materia l for Inspire.

Yes No

Unsupervised outing permission Students 14 years and older wi l l have the opportunity , on tr ips and vis its , to go out in smal l unsupervised groups (minimum 3 students per group).

Yes No

Travelux Limited,9/F, So Hong Commercial Building,

41-47 Jervois Street, Sheung Wan, Hong KongTel: +852 2526 6163 Email: info@travelux.hk

REGISTRATION FORMST. ANNE'S COLLEGE, OXFORD FOR 16-19 YEAR OLDS Please write in CAPITALS

• CREDIT CARDMastercard

/

VISAI wish to pay HKDCard number:

Expiry date:

Security code:

Name of cardholder:

Address of cardholder:

Signature of cardholder:

� �• BANK TRANSFER

I wish to pay by bank transfer and enclose a copy of the bank transfer papers .

CONFIRMATION

I agree to the use of my chi ld’s personal information, including health and rel ig ious or dietary requirements, as in the terms and condit ions.

Yes No

I agree that you can send me occasional information about Inspire.

Yes No

Please s ign below to conf irm that you accept the Terms and Condit ions of this booking as on the Inspire website, and that the student wi l l comply with Inspire rules and regulat ions. (This conf irmation must be s igned to guarantee a place on a course).

Signature:

Date:

Travelux Limited,9/F, So Hong Commercial Building,

41-47 Jervois Street, Sheung Wan, Hong KongTel: +852 2526 6163 Email: info@travelux.hk

REGISTRATION FORMST. ANNE'S COLLEGE, OXFORD FOR 16-19 YEAR OLDSPlease write in CAPITALS

PAYMENT Ful l payment must be sent with this registrat ion form to guarantee your place. Please choose from a payment option below.

Method of payment