2021 Bookings APPLICATION FORM 1Enter Your Details2School Information3Course Details4Emergency Contact Details5Acceptance & Payment Student DetailsPlease enter the personal details of the student below, fields marked with an * are required.Student Name* First Last Gender* Male Female Student Date of Birth*(Students must be between 10-18 years of age at the start of the course date)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Home Address* Address Line 1 Address Line 2 Town County Parent Mobile No.*(This will be the main contact number for calls and SMS messages)Second Parent Mobile No.Email Parent*(This will be the email address used for correspondence ) School DetailsPlease enter details of your school and any college attended previously School* School Address* Address Line 1 Address Line 2 Town County Class/Year*Please enter student’s present class/ year group in school 1st Year 2nd Year 3rd Year Transition Year 5th Year Primary 5th Class Primary 6th Class Name of Irish Teacher* Irish College at which you previously attended Course DetailsChoice of Course*Cúrsa A: 06/06/21 – 19/06/21 - 1st & 2nd years only - €780 Cúrsa B: 20/06/21 – 03/07/21 - 1st & 2nd years only - €780 Cúrsa C: 04/07/21 – 17/07/21 - All students - €780 Cúrsa D: 18/07/21 – 31/07/21 - All students- €780ABCDSecond Choice of Course*Your preferred course may be unavailable, so please select your next alternative course.ABCDPast Pupil*Are you a past pupil of Coláiste Chonnacht?YesNoGuesthouseGuesthouse of your choice if there is room. To be completed only by past pupils. Preferred Guesthouse cannot be guaranteed. FriendName of one friend you wish to be accommodated with. Emergency Contact DetailsPlease enter details of your emergency contact and any medical issues we need to be aware of:Emergency Contact If parents are away during course state the name and telephone number of person who would be responsible for child / children in case of emergency.Emergency Contact Telephone Medical DetailsProvide information on any health problems the applicant might have including existing medical illness and / or allergies. (Note: All medical fees are the responsibility of parents or guardian)Medical Card NoPlease note that all medical expenses are the responsibility of the parent/ guardian. Parents are advised that it is in their interest to have Personal Accident Insurance. (If you have a current medical card send copy of same with application.) Acceptance & PaymentA €250 Deposit Payment is payable on application. An online payment can be made below (subject to a €4.50 booking fee) or details of alternative payment options will be included in the booking confirmation email. Parent / Guardian Name* First Last Parent / Guardian Acceptance*Tick the box to denote acceptance of Terms and Conditions and College Rules. I consent to my submitted data being collected and stored in accordance with GDPR guidelines. Acceptance Confirmed DepositDEPOSIT (to Pay to secure your place) € 0.00 Method of Payment*Credit CardChequeBank DraftPostal OrderBank TransferPromotional Code If you are not paying the deposit today by credit card, further instructions for alternative payment methods will be emailed to you after submitting this form.
