First name:
Family name:
Title (Mr/Miss etc.):    

Address:


City:
Country:
Post Code:

Phone No (with code):
Fax No (with code):
Student's Mobile No:
Emergency contact name and number:
E-mail:

Nationality:
First Language:
Second Language (if bilingual)
Sex:          Male      Female
Date of Birth (dd/mm/yy):
Smoker:     Yes      No      
List any foods you cannot eat:
List Medical conditions/allergies:
Animals you are allergic to:
Medications you are taking:
Can you swim?

How long have you been studying English?
Level of English: Beginner Elementary Pre-intermediate Intermediate Upper intermediate Advanced

Have you attended a Harven course before?    Yes    No
If yes, which course(s) and year(s):
If no, where did you hear about Harven: (please select) British Council Agent Web site Advertisement Other
Details:

Are you preparing for an exam?   Yes    No
Which examination?
Do you wish Harven to register you for the Exam?    Yes    No

Course Selected:
Undecided Group StudyPlus Activate Group StudyPlus Complete Combined StudyPlus Combined StudyPlus Intensive Individual StudyPlus IELTS Examination Course English for teenagers ages 14-17 homestay
* Number of Individual StudyPlus hours per week (1 lesson = 1 hour): 0 7.5 10 15 20 25 30
(* You do not need to answer this for students aged 14-17)

Accommodation Required:
(none) Homestay Hotel
If none, please write below your address while studying:

Accommodation dates required
(dd-mm-yy):    
From:     To:
Lesson dates required (dd-mm-yy):    
From:     To:

Transfer arrangements required *:
(none)  

Chauffeur one way  

Chauffeur both ways  

Check-in service for under 16's  

--- which airport? --- Heathrow Gatwick Stanstead Luton * Please send flight details as soon as they are available.

Deposit has been paid by:
Credit/Debit Card    Bank Transfer

Bank Transfers should be made to:

You can also pay the deposit by credit card although note that this is not a secure (encrypted) form. We recommend that you print out this page and fax or post your credit card details to us.
VISA    MasterCard    Switch   

Solo    VISA Electron    Maestro   

Card No:
Valid from: (switch only)
Expiry date:
Issue No: (switch only)
3 digit security code:
Cardholder:
Cardholder's address:

For our cancellations and refunds policy, please see out Terms and Conditions