Student Enquiry Form (ETO)

Student Enquiry Form (ETO)
Agency Details
Agency name*
Agency contact name*
Contact email address*
The email address you would like us to contact you on.
Bucksmore Contact*
The member of the Bucksmore commercial team who manages your agency account.

Student Details
Number of students for course
Please note: for 2:1 courses where two students will be taught by the same teacher, please complete and submit this Jotform for both students separately.
First Name*
Last Name*
Gender*
Date of Birth*

DayMonthYear
This is required for insurance purposes
Nationality*
First Language*
Passport / ID number
English Level (CEFR)*
Has this student taken a Bucksmore course before?

YesNo
Does the student have any medical requirements that Bucksmore should be aware of?*

YesNo
If yes, please provide more medical information

Please include details of any medical information which the Bucksmore team needs to know. 0/255
Does the student have any learning or behavioural requirements or disabilities which Bucksmore should be aware of?*

YesNo
If yes, please provide more information on their learning & behavioural background or any disabilities

Please include details of any learning or behavioural information which the Bucksmore team needs to know. 0/255
Please list any allergies the student may have*
Hobbies and Interests*
Additional Student Details
If more than one student is taking the course. Please include their details here.

Course details
Arrival Date

DayMonthYear
Our courses usually begin on Sundays
Departure Date

DayMonthYear
Our courses usually end on Saturdays
My dates are flexible

YesNo
If the student dates are flexible, at what time of year would they like to study?
Number of Tuition Hours (per week)
Course type
Please note: for 2:1 courses where two students will be taught by the same teacher, please complete and submit this Jotform for both students separately.
Which exam is the student preparing to take?
If your student is planning to take an exam in the UK, it is your responsibility to book the exam after the course has been confirmed and ensure that their exam is available during the course dates.
Transfers required?
Additional Information or Requests
If you are unsure about any of the above, please provide more detail here.

Agency Details