Canadá Inesquecível - Programa de Férias em London, Ontario

Canadá Inesquecível - Programa de Férias em London, Ontario

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SHORT TERM APPLICATION FORM
Name of Agency: THAIS GONTIJO AND HIGH TURISMO
Country: BRAZIL

Applicant’s Last Name: First Name: Middle Names:

Date of Birth (Year/Month/Day):
Home Telephone Number (with area code):
Mobile Phone Number (with area code ):

Address

Street:  Neighborhood:  City:
Zip Code:  State:

Passport Number:  Citizenship:

E-mail address of parents:
Father:  Mother:

Mobile phone of parents (with area codes):
Father:  Mother:

Occupation of Parents / Name of Company:
Father:  Mother:

Work phone of parents (with area codes):
Father:  Mother:

Parent/Guardian Information:
Name 1: Address 1: Phone 1 (with area code):
Date of Birth 1: Email 1:

Name 2: Address 2: Phone 2 (with area code):
Date of Birth 2: Email 2:

ADDITIONAL INFORMATION:

ALLERGIES TO MEDICINES:

OTHER ALLERGIES:

SPECIAL DIETARY NEEDS:

SPECIAL HEALTH OR OTHER NEEDS:

IMPORTANT NOTES OR INFORMATIONS:

FOR A CASE OF EMERGENCY, YOUR DOCTOR´S CONTACTS AND PHONE NUMBERS:

LETTER OF INVITATION REQUIRED: YES

CUSTODIANSHIP REQUIRED (an additional $100 CDN):