Bodwell's University Summer Programs

PERSONAL DATA
Surname/Family Name:*
Given Name(s):*
English Name:
Gender:*	Male Female
Date of Birth:*
First Language:*
Country of Birth:*
Citizenship:*

MEDICAL INFORMATION*

Do you have any of the following medical conditions which may require special care?

       Severe asthma
       Life-threatening allergy
       Seizures / Epilepsy
       Diabetes
       Other

Please specify any other medical conditions.

Are you on any medication? If yes, please specify:

Do you have any allergies? If yes, please specify:

Please indicate any special food requirements:

FLIGHT INFORMATION (If applicable)
Do you require an airport pick-up?*	Yes No
If YES, please fill-in flight information below:
Arrival Date:
Airline & Flight Number:
Time:
Departure Date:
Airline & Flight Number:
Time:
If NO, please fill-in the check-in information below:
Check-in Date:
Approximate Time:
Checkout Date:
Approximate Time:

REGISTRATION WITH A BODWELL AGENCY (If applicable)
Agency Name:
Agency Contact:
Telephone:
Email Address:

CONTACT INFORMATION
Home Address:*

City:*
Province/State:*
Country:*
Postal/Zip Code:*
Telephone:*
Email Address:*

PARENT/GUARDIAN CONTACT INFORMATION
Parent/Guardian's Name:*
Telephone (Home):*
Telephone (Work):
Telephone (Mobile):
Email Address:*

Upon receipt of this application form, Bodwell's University Summer Programs will issue a letter of offer (invoice), stating the total fees owing and payment methods.
Spaces are not confirmed until program fees are paid in full.

I declare that the information given in this application is complete and correct to the best of my knowledge.