STUDENT APPLICATION

Student Application
Please fill out the form below, providing as much detail as possible.
Location*
Student Details
First Name*
Surname*
Preferred Name*
Gender*
Date of birth*
Nationality*
Student ID (If known)
Main languages spoken*
Student Contact Details
Email address*
Facebook / Wechat ID
Mobile phone number*
Parents Contact Details
Title*
First Name*
Surname*
Preferred Name*
Parent address*
Email address*
Facebook / Wechat ID
Phone contact*
Emergency Contact Details - Other
Emergency contact Name*
Relationship to student*
Landline phone*
Email address*
Facebook / Wechat ID
Mobile phone number*
Agent Contact Details
Agent company name
Branch / Office
Counsellor's Name
Email address
Office phone number
Mobile phone number
Course Details
Education institution attending*
Course Name*
Address/Campus location*
Course start date*
Course length in weeks*
Arrival Details (If known) & Accomodation Requirements
Flight arrival date
Arrival time
Flight number
Require airport pick-up*
Accommodation start date*
Accommodation end date*
Type of accommodation required*
Student Personal Details
Do you:
1. Have any medical conditions*
Details
2. Have any allergies*
Details
3. Need a special diet*
Details
4. Currently take medication*
Details
5. Smoke*
Details
Religion (optional)
Any special requests
Any other information you would like to tell us about yourself?*
Declaration:
Student requests are seriously considered but it may not be possible to meet all requests. Additional requests cannot be considered after placement confirmation or additional charges apply.
Do you agree to abide by Australia's Anti-Discrimination Law and Privacy Law. Please see below?
I agree to abide by the Anti-Discrimination Law*
I agree to abide by the Anti-Discrimination Law
I agree to abide by the Privacy Law*
I agree to abide by the Privacy Law
Have you read and agreed to the Auzzie Families Fees and Conditions. Please see below?
I agree to the Auzzie Families Fees and Conditions*
I agree to the Auzzie Families Fees and Conditions
Please include an email address to send confirmation of this form submission*
Name
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