Summer Language Camp Application Form: Filled out by Parents

Summer Language Camp Application Form: Filled out by parents:

Camper Information:

First Name / Click here to enter text. /
Middle Name / Click here to enter text. /
Last Name / Click here to enter text. /
Gender / Choose an item. /
Address / Click here to enter text. /
City / Click here to enter text. /
Country of Residence / Click here to enter text. /
Home Phone / Click here to enter text. /
Mobile Phone / Click here to enter text. /
Email / Click here to enter text. /
Date of Birth / Click here to enter a date. /
Country of Birth / Click here to enter text. /
Country of Citizenship / Click here to enter text. /
How many years has your child studied English? / Click here to enter text. /

Emergency Contact Details:

First Name / Last Name / Mobile Number / Email
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /

Family Information:

Family Member / First Name / Last Name / Email / Mobile Number / Work Number / Occupation / Date of Birth
Father / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Mother / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /

Personal Information:

Height in centimetres: / Click here to enter text. /
Weight in kilograms: / Click here to enter text. /
Do your child had any illnesses that caused hospitalization? Explain. / Click here to enter text. /
Do your child have any health condition, physical, or mental disability or allergic reaction in their medical history? Explain. / Click here to enter text. /
Do your child currently take any medications? If so, which ones? / Click here to enter text. /
Has your child ever suffered from depression? Had counselling/therapy? / Choose an item. /
Has your child ever had an eating disorder such as Anorexia or Bulimia? / Choose an item. /
Any allergy to pets or is there any reason that your child cannot live in a house with pets? Explain. / Click here to enter text. /
Is your child vegetarian or are there any foods they cannot eat because of health, religious or other reasons? Explain. / Click here to enter text. /
Does your child smoke? / Choose an item. /
Would your child live with a family that smokes, but not in the house? / Choose an item. /
What is your religion? / Click here to enter text. /
How often do you attend service? / Click here to enter text. /
If your host family was of another religion, would that be a problem for you? / Choose an item. /
Would your child be willing to attend religious services with your Irish host family? / Choose an item. /

Activities and Interests:

Alone: / Click here to enter text. /
With Family: / Click here to enter text. /
With Friends: / Click here to enter text. /
Sports: / Click here to enter text. /
Musical: / Click here to enter text. /
Indoor/Outdoor/Nature: / Click here to enter text. /
Please elaborate on your child’s favourite activities so that Home from Home can understand who they are and match them with a suitable and compatible family: / Click here to enter text. /