Partner Booking Form - Immerse Education

Partner Booking Form 2022

Section 1: Partner Details

Name of Your Educational Consultancy / Agency(Required)

Your Name(Required)

Your First Name Your Family Name

Your Email(Required)

Section 2: Enrolment Information

Location(Required)

Age Range(Required)

Cambridge - Ages 13-15

Programme Choice (Cambridge, Ages 13-15)

Programme Dates (Cambridge, Ages 13-15)

Cambridge - Ages 16-18

Programme Choice (Cambridge, Ages 16-18)

Programme Dates (Cambridge, Ages 16-18)

Programme Dates (Female Future Leaders, Cambridge, Ages 16-18)

Programme Dates (Cambridge, Ages 16-18)

Oxford - Ages 13-15

Programme Choice (Oxford, Ages 13-15)

Programme Dates (Oxford, Ages 13-15)

Oxford - Ages 16-18

Programme Choice (Oxford, Ages 16-18)

Programme Dates (Oxford, Ages 16-18)

London

Programme Choice (London, Ages 16-18)

Programme Dates (London, Ages 16-18)

Programme Dates (London, Law, Ages 16-18)

Sydney

Programme Choice (Sydney)

Programme Dates (Sydney)

Online

Programme Choice (Online)

Online Insights Programme Dates

As you have selected an online research programme, we will contact your student (with you in copy) for more information about their requested programme (i.e. subject choice, dates, tutorial time, etc) to create a bespoke programme.

Section 3: Participant Information

Participant Name(Required)

Participant First Name Participant Family Name

Participant Nationality(Required)

Date of Birth(Required)

Participant Preferred Pronouns(Required)

Participant Email(Required)

IMPORTANT - this is the email we use to send updates about the programme. If you do not want us to contact the student directly, please enter your own email.

Participant Phone Number(Required)

Dietary Requirements

Does The Participant Have Any Medical Conditions?(Required)

Medical Information - Additional Notes

Does The Parent/Guardian Content To The Child Receiving Over-The-Counter Medicine (If Unwell)?

Medicines to be distributed if needed: Paracetamol (for pain relief and fever reduction), Ibuprofen (for pain relief and fever reduction), Piriton (to relieve symptoms of mild allergies, such as hay-fever), Strepsils (for sore throat relief), Simple Linctus (for mild coughs), Rennie (for heartburn and indigestion), Olbas Oil (decongestant for colds / congestion).

Other Information

Section 4: Parent / Guardian Details

Parent Name

Parent First Name Parent Family Name

Parent Email

IMPORTANT - this is the email we use to send updates about the programme. If you do not want us to contact the family directly, please enter your own email.

Parent/Guardian Phone Number

Section 5: Emergency Contact Information

Emergency Contact Name

Emergency Contact First Name Emergency Contact Last Name

Emergency Contact Email

Emergency Contact Phone Number

Emergency Contact Phone (Alternative)

Confirmation

Please Click Here To View Our Terms & Conditions

Do you and your client accept the terms and conditions?(Required)

Yes

Invoice Email(Required)

Which Invoice Would You Like To Receive?

Additional Notes

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