Institute of St Marcellina
Residence
Hampstead Towers

 

 


 

Summer Course
under 18
Application

Page 4 of  4    go to home page  

Application for ADMISSION

print this page, complete form and send to:
The Institute of St. Marcellina
Hampstead Towers
6, Ellerdale Road
London, NW3 6BD



(Please use BLOCK LETTERS)

Full  name_______________________________________________________
Date of Birth __________________________  Place of Birth______________
Nationality ____________________________ Religion____________________
Fatherís Name___________________________________________________
Motherís full name________________________________________________

Address in your own country ________________________________________
______________________________________________________________
Telephone _____________________________Mobile phone
_______________
E-mail__________________________________________________________


Name of the School_______________________________________________
Class attended_________________________Years of English study: ________
References______________________________________________________

People authorised to visit the student__________________________________

FOR SAFETY REASONS SMOKING IS NOT ALLOWED

Signature of the Parents__________________________________________ 

    Signature of the Student__________________________________________

Date____________________________________