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* Name of the school
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2) Town/city (to be filled in only if 2 destinations)
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Name of the school
Start date
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Wishes concerning the host family
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yes
no
don't mind
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no
don't mind
Family with students
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no
don't mind
Family with pets
yes
no
don't mind
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* I wish to receive an offer for the flight
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Personal details
* Title
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* Surname
* First name
* Date of birth
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* Place of birth
* Nationality
Afghanistan
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Angola
Anguilla
Antarctica
Antigua & Barbuda
Argentina
Armenia
Aruba
Australia
Austria
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Botswana
Bouvet Island
Brazil
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Burkina Faso
Burundi
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Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
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Democratic Republic of the Congo
Denmark
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Dominica
Dominican Republic
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Egypt
El Salvador
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Estonia
Ethiopia
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Faroe Islands
Fidji, Is
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Great Britain
Greece
Greenland
Grenada, Is
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libyan
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru, Is
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau, Is
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Sainn Vicent
Saint Helena
Saint Kitts and Nevis
Saint Lucia, Is
Saint Pierre and Miquelon
Samoa
Samoa, Is
San Marino
Sandwich Islands
São Tomé and Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu, Is
Uganda
Ukraine
United Arab Emirates
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu, Is
Vatican City
Venezuela
Viet Nam
Virgin Islands
Virgin Islands
Wallis and Futuna
Yemen
Zambia
Zimbabwe
* Mother tongue
* Language level
Beginner
Elementary (A1)
Upper elementary (A1-A2)
Lower intermediate (A2)
Intermediate (A2-B1)
Upper intermediate (B1-B2)
Advanced (B2-C1)
Upper advanced (C1-C2)
Close to mother tongue (C2)
Profession
* Address
* Postcode
* City/town
* Country
Afghanistan
Albania
Algeria
Andorra
Angola
Anguilla
Antarctica
Antigua & Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkand Islands
Faroe Islands
Fidji, Is
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Great Britain
Greece
Greenland
Grenada, Is
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libyan
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru, Is
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau, Is
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russian Federation
Rwanda
Sainn Vicent
Saint Helena
Saint Kitts and Nevis
Saint Lucia, Is
Saint Pierre and Miquelon
Samoa
Samoa, Is
San Marino
Sandwich Islands
São Tomé and Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu, Is
Uganda
Ukraine
United Arab Emirates
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu, Is
Vatican City
Venezuela
Viet Nam
Virgin Islands
Virgin Islands
Wallis and Futuna
Yemen
Zambia
Zimbabwe
* Private tel.
Work tel.
Mobile
Fax
* E-mail address
If student, school attended
Contact person during your stay
* Surname
* First name
* Private tel.
Language level
* Written
A1 Elementary
A2 Pre-Intermediate
B1 Intermediate
B2 Upper-Intermediate
C1 Advanced
C2 Proficient
* Oral
A1 Elementary
A2 Pre-Intermediate
B1 Intermediate
B2 Upper-Intermediate
C1 Advanced
C2 Proficient
* Qualifications
Only for in-service teachers
Name and address of educational institution where you currently work
How long have you been teaching?
0-2 years
3-5 years
5-10 years
10-20 years
20 years+
Levels taught
A1
A2
B1
B2
C1
C2
Mixed Ability
Ages of students you teach
4-6
7-9
10-12
13-15
16-18
18+
What books/resources do you use to teach?
Do you teach any subjects other than Language?
Do you teach other subjects through English (CLIL)?
Do you have knowledge of any other languages?
Funding
Have you received confirmation of funding yet?
yes
no
If No, please give the reasons for not receiving funding
I am not an EU national
I have been refused Comenius or Grundtvig funding
I have received Comenius or Grundtvig funding too recently in the past
I will pay my own course fees
Miscellaneous
I am a vegetarian
yes
no
I am a smoker
yes
no
Special diet
Allergies/Medical treatment
Leisure, interests
Other wishes
Insurances
* I wish to receive a
cancellation-assistance insurance
- 3 months (EUR 55.-)
yes
no
* Extension of the assistance insurance: (EUR 6.30 per month)
yes. Number of months
no
* I wish to have free exam cancellation protection (please send us proof of enrolment for an exam)
yes
no
Confirmation & sending
* I completely agree with the
general terms and conditons
of ESL.
* How did you find out about ESL?
A friend
I am a client
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