Application
English in Canada - Destination Canada
International Summer Language  Camp at
 Carleton University in Ottawa
Fax or Mail  1 photo & original application to Lisbeth Graverholt    
         English in Canada, Hjørring Gymnasium, 9800 Hjørring
Phone & Fax: 98911425
lisbeth.graverholt@skolekom.dk


Family name

First name

 Age by July 1

 Sex:  
Birth date (day/month/year)
              
Address City Postal code
Home Phone Home Fax

e-mail
Citizenship Passport Number

 Place of Birth
Mother's Name Occupation

Bus. Phone
Father's Name

Occupation

Bus. Phone
Has participant lived in a foreign country?
Where?		 yes ___     
no ___		 How long?
Does participant suffer from medical problems? Medical treatment required?

 Yes ___
Please attach explanation.		 No ___
Your English level:     Low Beginner ____  High Beginner ____ 
                                     Low Intermediate ____  		High Intermediate____ Advanced ____

Name and address of home school

 

 Phone

e-mail

Name of home school Principal/Director

Name of English teacher:

E-mail:
.
E-mail:
Registering for the following session:  3 weeks ___      
                                                                          4 weeks ___		 Niagara Falls Tour          Yes ___ No __
Provide complete flight schedule to Ottawa Airport (may be submitted at a later date)  Date and time of all flights  

 

 
For Guardians
Permission - In enrolling my child I hereby agree to permit the camp doctor or nurse to administer such routine medication as they deem advisable in the event of an emergency. If camp doctors are not able to contact either parents, the directors are hereby given permission to act on the parent's behalf in signing permission for medical care as advised by a medical doctor.		 Signature of Parent/Guardian Date                     
Signature of Parent / Guardian Date