Enrollment Form – Step 2/3

Atlantic Language Galway – Galway, Ireland

Personal Details

Title^*	Ms. Mr.
First Name^*		Family Name^*
Street^*		No.^*
City^*		Postal Code^*
State/Province
Country^*
	My country is not listed
Date of Birth^*
Nationality^*
Passport No.^*
Native Language		Foreign Languages
Phone (home)^*		Phone (work)
Phone (mobile)		Fax
e-mail^*
e-mail^*	(Please re-enter to confirm)
Medical concerns	yesno	Medical detail
Do you smoke?	yesno
Hobbies
Name, address and telephone number of emergency contact:^*

Homestay Questions
To help us choose the right family for you, please provide the following information if you are booking host family accommodation.

Would you accept living in a house with smokers?	yesno
Would you accept living in a house with pets?	yesno
Would you accept living with other students?	yesno
Would you accept to live with small children?	yesno
Do you require a special diet (e.g. vegetarian)?	yesno
Diet detail

Insurance
Add extensive travel insurance (health, accident and liability) with worldwide coverage to your booking for only per day. We also offer trip cancellation and curtailment insurance for 6% of the total booking price.
Insurance Dr. Walter Travel and Education Insurance (intra EU) (Coverage and Conditions) Dr. Walter Travel and Education Insurance (EU incoming) (Coverage and Conditions) Dr. Walter Travel and Education Insurance (World) (Coverage and Conditions) Dr. Walter Travel and Education Insurance (North America) (Coverage and Conditions) Cancellation Insurance (Coverage and Conditions)

Other Information
Requests / Comments

How did you find this Website? ^*
General Terms and Conditions
I have read and agreed to the general terms and conditions of the school.
I have read and agreed to the general terms and conditions of Timpany.