Excel Academy Enrolment Form

Enrolment Form
Please complete this form in ENGLISH
Full name*
English name
Date of birth*

DayMonthYear
Gender*
Name of School:*
Form/class at the start of the academic year*
Please upload a passport-sized photo/selfie:

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Home address line 1*
Home address line 2*
Home address line 3*
Student's mobile number:*
(+852) ########
(parents/guardians, there is a section for your telephone number later in the form)
Student's email address *
(parents/guardians, there is a section for your email address later in the form)
Please tick 3 traits to best describe your personality*

IndependentReservedAdaptableLivelyDynamicMatureQuietTalkative
Please tick 3 traits to best describe your interests*

SportsMusicGames (e.g. chess)DancingTV/moviesComputersArt/drawing
RESIDENTIAL PREFERENCES AND HEALTH INFORMATION

Please note, Excel cannot guarantee that room‐type preferences (e.g., single or twin bedroom) will be met in all cases.
Friend's name you would like to be your buddy (only one, if applicable):
Make sure your friend agrees and writes YOUR name on their form!
Please specify any special dietary requirements (leave blank if none):
e.g. vegetarian
Please specify any food allergies (leave blank if none):
e.g. nuts, fava beans
If you have any food allergies, please specify severity if consumed:
e.g. very severe (hospitalisation), severe (medication), mild (no action required)
Please list any food allergy medication, including dosage (leave blank if none):
If you require medication for food allergies please confirm you will bring it with you, are aware of the dosage and how to take it:

YesNo
Please indicate any allergies (leave blank if none):
e.g. to medicines, antibiotics
Please state any current medical conditions (leave blank if none):
e.g. asthma, epilepsy, attention deficit disorder (ADD)
Please indicate any other medication you will be bringing with you (leave blank if none):
Please confirm that you are aware of the dosage and how to take it:

YesNo
Please rate your standard of English on a scale of 1-5, where 1 is the lowest and 5 is the highest:
Reading*
Speaking*
Writing*
Grammar*
Listening*
Vocabulary*
Which two aspects do you wish to improve the most?*

ReadingWritingListeningSpeakingGrammarVocabulary
Father's name:*
Father's mobile number:*
(+852) ########
Father's email address:*
Mother's name:*
Mother's mobile number:*
(+852) ########
Mother's email address:*
Please provide up-to-date, valid email addresses for correspondence relating to your child's application. Your information will not be shared with any third party
ADDITIONAL INFORMATION (Please include any additional information which you feel may be relevant to your application e.g. reasons for applying for this trip, special departure information, other emergency contact details)
I give permission to the Excel Academy representative to take any appropriate measures in an emergency, which are deemed necessary to safeguard the well-being of my child*

Yes
I accept responsibility to undertake all necessary arrangements (including payments) to repatriate my child in case of emergency resulting from illness, serious accident or unacceptable behaviour, as deemed by the Excel Academy*

Yes
I accept responsibility to pay for any damages (accidental or otherwise) caused by my child upon receipt of a valid report & receipt/ invoice*

Yes
I will make sure that my child follows the instructions of their accompanying group leader(s) and Excel Academy staff while they are staying in the UK*

Yes
I understand that during the programme, my child is NOT allowed to go on any unauthorised or unsupervised outings*

Yes
I accept the Excel Academy's curriculum enrichment programme terms & conditions listed above and included in the brochure (online version at: https://www.excelacademy.london/brochure)*

Yes
I confirm that my child is up-to-date with their immunisation and is healthy (both physically and mentally) to participate on the programme*

Yes
I give consent to the Excel Academy to take photographs of my child for internal purposes, including the programme's blog

Yes
Date

DayMonthYear
Date
Parent/Guardian's full name*
Parent/Guardian's signature*

Please upload a scanned or digital signature
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Please inform us if you do not wish photographs of your child to be used for external purposes, e.g. brochures
Please tick here if you wish to be included on the Excel Academy’s alumni mailing list:*

YesNo
Should be Empty:

Enrolment FormPlease complete this form in ENGLISH

Enrolment Form
Please complete this form in ENGLISH