Parental Consent Form - ESL - Atlantic Language School Galway

This form must be completed by the parent/guardian of any student under the age of 18 attending a course at Atlantic Language.

Student Details

Family Name *

BROWN

First Name *

Mr. Jacob

Student ID *

(123456)

Date of Birth *

31/12/1999

Age (on Arrival) *

15

Student Email *

Student Mobile Phone *

Nationality *

Start Date *

Finishing Date *

Parent / Guardian Details (Complete in Full)

Family Name *

BROWN

First Name *

Mr. John

Date of Birth *

31/12/1960

Age *

Gender *

Male

Female

Relation to student *

ie. Father / Mother

Email *

Phone *

Mobile Phone

Please answer all of the following questions

Has your child any medical conditions or allergies? If yes, please give details. * Has your child any medical conditions or allergies? If yes, please give details.

Is your child taking any medication? If yes, please give details. * Is your child taking any medication? If yes, please give details.

I agree to my son/daughter receiving medication as instructed under medical supervision. *

I agree to any emergency dental, medical / surgical treatment, including anaesthetic / blood transfusion, as considered necessary by medical authorities. *

My son’s/daughter’s EHIC (European Health Insurance Card) Number *

AG245691 [Please put N/A if you do not have a European Health Card]

EHIC (European Health Insurance Card) issued by (name of organisation) and Expiry Date

Issued By *

[Please put N/A if you do not have a European Health Card]

Expiry Date *

[Please put N/A if you do not have a European Health Card]

Conditions of Acceptance

Attendance at class, schedule activities, and excursions is compulsory.
Students with special dietary or medical considerations are accepted solely at the discretion of Atlantic Language. Students with enuresis cannot be accepted.
The use of alcohol, drugs or other proscribed substances is strictly forbidden. Students found in possession of alcohol, drugs or other proscribed substances will be sent home immediately at parents’/guardians’ expense. Parents/guardians will be advised of the termination of the student’s stay and must make arrangements for the student’s immediate return home. No refund of fees will be permitted in this circumstance.
Under the provisions of Irish law, young people under the age of 18 years of age may not visit public houses (pubs) and they may not purchase alcohol.
A student is responsible for any damage or injury he/she may cause to buildings, furniture, fittings, individuals’ or host family property, etc., while registered with Atlantic Language. The student and his/her parents/guardians will be responsible for the repair, replacement or reimbursement of any damaged property
Where theft of property from the school, host family, another student or any other location, occurs the matter will be referred to the Irish police service, An Garda Síochána, who will investigate the matter and deal with it according to Irish legal procedures.
A serious misdemeanour or infringement of the laws of Ireland will result in instant dismissal from the school. Costs incurred by the student as a result of dismissal from the school are the sole responsibility of the student and his/her parents/guardians. Atlantic Language will accept no liability of any kind.
All students are subject to a curfew: they must be at their nominated host family or school residence by 22:30 each night.

* IMPORTANT *

Do you give permission to your child to exit the campus / accommodation unaccompanied during his/her free time as long as he/she returns to the campus / accommodation by the specified curfew time of 22:30? *

Yes

No

Do you give us permission to take pictures of him/her to support his/her testimonials, and to use his/her comments and photos for promoting or advertising purposes? *

Yes

No

I have read and understood the conditions of acceptance, and have explained the school rules to my child. *

Yes

No

Submitted by (FULL NAME) *

Date *

31/01/1990

Parental Consent Form – ESL