Student Application

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

Have any medical conditions*

Have any allergies*

Religion (optional)

Need a special diet*

Currently take medication*

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 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

Please include an email address to send confirmation of this form submission*