INTENSIVE TRAINING COURSE (under 18 s) with full board 2018 INSCRIPTION FORM NAME : SURNAME : ADDRESS : POSTAL CODE : TOWN : COUNTRY :.. TEL :..././.

Size: px
Start display at page:

Download "INTENSIVE TRAINING COURSE (under 18 s) with full board 2018 INSCRIPTION FORM NAME : SURNAME : ADDRESS : POSTAL CODE : TOWN : COUNTRY :.. TEL :..././."

Transcription

1 INSCRIPTION FORM NAME : SURNAME : DATE OF BIRTH :... SEX : male female ADDRESS : POSTAL CODE : TOWN : COUNTRY :.. TEL :...././. TENNIS LEVEL For non-classified players : How long have you been playing tennis?..., How many hours a week do you practise on average?..., Have you played in tournaments :.., Your level is equivalent to the player classified as :. Your level : Beginner who has played a little, Average. LEVEL For classified players : Classification 2018 :.. DATE : From. To 2018 Licence number FFT*: *French Tennis Federation E MAIL* :.....@ *(Confirmation of reception will be sent by E Mail) 1

2 PARENTS AUTHORIZATION PARENTS NAME:... SURNAME : TRAINEE S NAME : SURNAME :.. ADDRESS : PHONE/ Mobile :.... House :.... E MAIL Medical information : Medical antecedents :.. Blood group : Allergies : Special mention :. 1 I, the undersigned, Mr. Mrs..authorize Monsieur FRANCK LEROUX to act on my behalf in case of emergency, medical care or hospitalisation. I agree to reembourse l Académie de tennis Franck LEROUX for any eventual medical, surgical, chemist costs and all the costs for taking care of my son or daughter. 2 Furthermore, I grant Franck LEROUX and his staff the permission to transport my child by all means of transport used (private or rented car, bus, taxi, train, boat) 3 Grant my child the authorization to take part in the proposed activities (especially swimming in the Bay or at the ocean) 4 I hereby certify that my child has a civil responsability insurance policy for any damage he or she might cause. Agreed in (name of your town) on. Signatures : (preceded by the mention «lu et approuvé» read approved ) 2

3 PAYMENT FEES :Intensif Course 5 days : days : days : Down-payment : Cheque for 25% of Total Fee : Airport Transfer : Transport costs for internet scheduled flights : return 40, one way 20, for all other flights, return 60, one way 30 : Total:. 3 Cancellation and Course Interruption Insurance yes no, 5 jours : 23, 12 Jours :46, 19 Jours : 69 Total:. 4 The photocopy of the 2018 licence (also available at the tennis club, it costs 20 ) 20, Total:. Total cost 25% of total fee + N 2,3,4 : If you to pay by bank transfer: (attention the expenses of transfer for countries except European community are at your expense) : MR FRANCK LEROUX REFERENCES BANCAIRES INTERNATIONALES: IBAN : FR L40 BIC :CRLYFRPP ADRESSE BANQUE: CREDIT LYONNAIS ARCACHON. 175 BD DE LA PLAGE ARCACHON. FRANCE As the parent or tutor of the enrolled child, I hereby certify that I have been informed of the general conditions of enrollment and paticipation in l Académie Franck Leroux and I agree to abide by these conditions. Signatures : (including the mention «lu et approuvé» - read and approved) The total fee must be paid 30 days (at the latest) before the course begins. There will be no confirmation by return post for the balance payment. 3

4 ARRIVAL AND DEPARTURE TIMES NAME : SURNAME :.. ARRIVAL : please note the precise date and time 1 Arrival at Arcachon la DUNE, 156 bd de la côte d Argent on the / /2018 at 5 P.M. 2 Arrival on Sunday in the S.N.C.F. railway station in Arcachon (we pick you up) the / /2018 at (time) Train N :.. 3 Arrival on Sunday in Bordeaux Mérignac Airport. We pick you up for all flights proposed on our internet travel site at a cost of 20 and all other flights (foreign) at a cost of 30 the / /2018 at (time) Flight N : DEPARTURE : tick the appropriate box ALL DEPARTURES ARE ON Saturday MORNING. Your parents pick you up at Arcachon,la Dune, 156 bd de la côte d Argent on the / /2018 at 5 P.M. We will take you to the station on Saturday morning (please precise your departure time) :.. You are picked up on Saturday morning the.. / /2018 at the tennis club, at the Dune Centre We take you to Bordeaux Mérignac Airport on Saturday morning at a further cost of 20 or 30 per person per trip the / /2018 departure time :... flight N.... 4

5 INTENSIVE TENNIS TRAINING COURSES (for under 18 s) WITH FULL BOARD AND LODGINGS AT ARCACHON TENNIS CLUB. 24-HOUR SUPERVISION ) Enrolment procedure ENROLMENT CONDITIONS: The following completed forms must be sent to the following address : ù The completed enrolment form ACADEMIE DE TENNIS FRANCK LEROUX, TENNIS CLUB D ARCACHON 7, avenue du Parc ARCACHON FRANCE Parents permission Photocopy of 2018 licence (if you haven t got a licence, you will be issued with one at the club. It costs 20 and it is valid for one year. A Doctor s Certificate which doesn t prevent the trainee from practicing competitive sport (At enrolment,download the example on tennisleroux.com and have it filled in and signed by your doctor.) A 25% down-payment, the balance must be paid, at the latest, 30 days before the beginning of the course Course cancellation or interruption Insurance is optional. This insurance covers sprains, muscle injuries, any sickness during the course etc (see conditions) For fuller information, consult the contract.. Arrival and departure form, as well as any eventual transport costs from Bordeaux Airport (40 or 60 the return trip) 2) Following your enrolment On reception of your enrolment, you will immediately receive confirmation by , on condition that the enrolment is received 3 weeks prior to the beginning of the course. 3) Complete Fee Payment Complete fees must be paid, at the latest, 30 days before the beginning of the course without any remainder on our behalf. 4) Cancellation Phone and confirm by registered letter as soon as possible. If you cancel more than 30 days before the beginning of the course, you down-payment will be refunded, less 50. You lose your down-payment for any cancellation between 6 and 30 days before the beginning of the course. No refund for any cancellation within 3 days of the beginning of the course. No refund for any absence without prior notification. Trainees must pay the complete fee for any course which they have started. 5) Cancellation Guarantee Cancellation and Interruption Insurance is optional. It covers the costs of sprains, muscle injuries, tec with complete reemboursement, no matter what the cancellation date. For further information, see contract. 6) L Académie de tennis Franck Leroux The Academy reserves the right to cancel a course if the number of trainees is insufficient to form a group. Timetable notifications may be necessary for a more practical organization. When a course is cancelled by the Academy, all payments will be refunded. 7) Medical Costs In the case of sickness or accident, the Académie de Tennis must be refunded for all its medical expenditure within one month of the end of the course. 8) Community life As with the participation in any holiday camp, all rules and regulations must be strictly adhered to. Any unacceptable behaviour which threatens the physical or moral well being of others trainees, such as smoking, taking drugs, alcohol as well as robbery, are stricktly prohibited. Trainees may be expelled from the course for the non-respect of these rules, and parents will cover all transport costs and pay the complete course fee. 9) Photographs I hereby grant l the permission to use any photo of my child taken during the course for commercial and communication use. 5

6 ACCESS Insurance broker - ACE Europe Group Insurance coverage in case of cancellation and Interruption BEFORE THE INCEPTION OF THE TRAINING COURSE, the coverage include: - Serious illness, serious accident, death of the trainee or of a member of his family - Sprains, pulled muscles and any other ailment preventing trainee from playing tennis - Important material damage to personal belongings when physical presence is mandatory - Redundancy of the trainee, his father or his mother YOU WILL BE REIMBOURSED - 25% of the total fee, in case of the event insured occurs 30 days prior to the date of the beginning of the training course % of the total fee, in case of the event insured occurs within the 30 days of the beginning of the training course. 2. AFTER THE INCEPTION OF THE TRAINING COURSE, the coverage include: - Serious illness, serious accident, death in the family affecting a trainee or a member of his family - Sprains, pulled muscles and any other ailment preventing trainee from playing tennis - Important material damage to personal belongings when physical presence is mandatory - Redundancy of the trainee, father or mother You will be reimbursed pro-rata of the period insured starting from the date of the claim DEDUCTIBLES - Cancellation for any medical reason before the inception of the training course : 10% of the amount insured with a minimum of 50 - Others events insured : None EXCLUSIONS - NOT INCLUDED IN THE COVERAGE - Any disaster, damage or loss caused intentionally by the trainee (included suicide) - Accident, illness or death : occurring before the beginning of the coverage of the training course insurance policy, due to a chronic disease a mental illness or depression/nervous breakdown with hospitalization of less than 3 days. INSURANCE PREMIUM : 5 jours : 23, 12 Jours :46, 19 Jours : 69 IN CASE OF CLAIM: Please, Inform us within 48 hours SUBSCRIPTION FORMS (to be returned with the course enrolment form) For payment by cheque, please write at the order of ACCESS Assurances NAME : SURNAME :. ADDRESS: COUNTRY:... DATE OF TRAINING COURSE:... AMOUNT OF THE TRAING COURSE INSURED:. I enclose the fee of. Lu et approuvé (Read and approved) Signature: ACCESS ASSURANCES 11 rue du Professeur Delmas Marsalet Bordeaux Tel : ou ACE Europe France is a subsidiary of ACE Europe group limited based in London 6

7 Mandate to be completed for accommodation, FFT license 2018 or Access Insurance undersigned Mrs. Mr... (Name of student's parents) Gives warrant for his account to Mr Franck LEROUX: the organisation of his half-board accommodation at the "La Dune" at 156 BD de La Côte d'argent in Arcachon... (Date of the tennis course) Purchase of its FFT 2018 tennis license from the FFT or the Tennis Club of Arcachon (check only for foreigners) Purchase of the access insurance from Ace Europe Group (check only for foreigners) Date and signature 7

TENNIS TRAINING COURSES & FRENCH LESSONS (for under 18 s) WITH FULL BOARD AND LODGINGS AT ARCACHON TENNIS CLUB. 24-HOUR SUPERVISION 2016

TENNIS TRAINING COURSES & FRENCH LESSONS (for under 18 s) WITH FULL BOARD AND LODGINGS AT ARCACHON TENNIS CLUB. 24-HOUR SUPERVISION 2016 ENROLLMENT CONDITIONS: 1) Enrolment procedure The following completed forms must be sent to the following address : ACADEMIE DE TENNIS FRANCK LEROUX, TENNIS CLUB D ARCACHON 7, avenue du Parc 33120 ARCACHON

More information

INTENSIVE TENNIS TRAINING COURSES & TOURNAMENTS (for under 18 s) WITH FULL BOARD AND LODGINGS AT ARCACHON TENNIS CLUB. 24-HOUR SUPERVISION 2019

INTENSIVE TENNIS TRAINING COURSES & TOURNAMENTS (for under 18 s) WITH FULL BOARD AND LODGINGS AT ARCACHON TENNIS CLUB. 24-HOUR SUPERVISION 2019 INTENSIVE TENNIS TRAINING COURSES & TOURNAMENTS (for under 18 s) WITH FULL BOARD INSCRIPTION FORM NAME : SURNAME : DATE OF BIRTH :... SEX : male female ADDRESS : POSTAL CODE : TOWN : COUNTRY :.. TEL :...././.

More information

INTENSIVE TRAINING COURSE (under 18 s) with full board 2019 INSCRIPTION FORM NAME : SURNAME : ADDRESS : POSTAL CODE : TOWN : COUNTRY :.. TEL :..././.

INTENSIVE TRAINING COURSE (under 18 s) with full board 2019 INSCRIPTION FORM NAME : SURNAME : ADDRESS : POSTAL CODE : TOWN : COUNTRY :.. TEL :..././. INTENSIVE TRAINING COURSE (under 18 s) with full board 2019 INSCRIPTION FORM NAME : SURNAME : DATE OF BIRTH :... SEX : male female ADDRESS : POSTAL CODE : TOWN : COUNTRY :.. TEL :...././../... TENNIS LEVEL

More information

710.%$ %89-1 +!!0 /9., ! " # $% $& ' (

710.%$ %89-1 +!!0 /9., !  # $% $& ' ( %5 6$6 710.%$ %89-1 +0 /9., # $% $& ' ( 3 '. 14 ' ) * *+, 2 5 -,./ 0 1-2 /01& #$ $%&% $ $ #$%&' (%$)& * +, - #./ )# - 0( Registration form 1. Personal details 2. Course Family name: First name: Title:

More information

LEMANIA SUMMER CAMP APPLICATION FORM SWITZERLAND

LEMANIA SUMMER CAMP APPLICATION FORM SWITZERLAND Ecole Lémania Fondée en 1908 LEMANIA SUMMER CAMP APPLICATION FORM 2018 - SWITZERLAND ECOLE LEMANIA Chemin de Préville 3 1003 Lausanne Switzerland Tel +41 (0) 21 320 15 01 info@summercamp.ch www.summercamp.ch

More information

Final date: English Intermediate. Advanced How did you get to know our programmes? Male

Final date: English Intermediate. Advanced How did you get to know our programmes? Male application form LANGUAGE EDUCATION IN SPAIN 10 to 15 years old This application needs to be accompanied with the proof of payment of the programme selected. Should you wish to include the cancellation

More information

Wembley Cup Wembley Stadium, London Saturday 7th October

Wembley Cup Wembley Stadium, London Saturday 7th October Wembley Cup Wembley Stadium, London Saturday 7th October Travel arrangements and times: Please keep this information for future reference. Travel by Coach. Unless you make arrangements to the contrary,

More information

Justin Bieber The O2, London Tuesday 11th October 2016

Justin Bieber The O2, London Tuesday 11th October 2016 Justin Bieber The O2, London Tuesday 11th October 2016 Travel arrangements and times: Please keep this information for future reference. Travel by Minibus. Unless you make arrangements to the contrary,

More information

GIRLS SUMMER PROGRAM 2019 Registration forms

GIRLS SUMMER PROGRAM 2019 Registration forms TINY STARS (2007-2009) FUTURE STARS (2005-2006) STARS (2004-1999) WEEK 1 (July 1 7): FUTURE STARS / TINY STARS WEEK 2 (July 8 14): FUTURE STARS / STARS WEEK 3 (July 15-21): FUTURE STARS / STARS (Includes

More information

Address: City: State/Province: ZIP/Postal Code: Height: Weight: Shot: LEFT RIGHT. Current team/level: How did you hear about HTI?

Address: City: State/Province: ZIP/Postal Code: Height: Weight: Shot: LEFT RIGHT. Current team/level: How did you hear about HTI? AGES: Youth Junior College Spring TRAINING PROGRAM 2019 Player Name: Date of Birth (mm/dd/yyyy) Address: City: State/Province: ZIP/Postal Code: Home Phone: Cell Phone: Email: Mother: Work/Fax: Father:

More information

Work Phone. Mobile / / Policy Number Date Issued Number of Travellers. Date of Booking Departure Date Return Date Total Days

Work Phone. Mobile / / Policy Number Date Issued Number of Travellers. Date of Booking Departure Date Return Date Total Days Travel Insurance Claim Form Cancellation You must register any claim within 30 days of completion of your travel. Please supply original documents of the evidence you intend to rely on for your claim,

More information

Learning Without Limits

Learning Without Limits Learning Without Limits Address: West Haddon Rd Guilsborough, Northampton, NN6 8QE T: 01604740641 F: 01604 749104 Principal: Mrs J S Swales BSc (Hons) Activity: Sports Tour Venue/Destination: Barcelona,

More information

(aged 13-17) Tarragona. Starting Dates. Course fee. Enrolments. Insurance

(aged 13-17) Tarragona. Starting Dates. Course fee. Enrolments. Insurance Tarragona (aged 13-17) 2016 This course takes place in the coastal resort of Tarragona, approx. 100 km south of Barcelona. The course includes 3 hours of Spanish tuition per day, full board accommodation

More information

The Abitur Exam Preparation Course offers a total of hours of tuition per week, including: - 15 Quatorial hours (4:1) - 10 One-to-One Abitur

The Abitur Exam Preparation Course offers a total of hours of tuition per week, including: - 15 Quatorial hours (4:1) - 10 One-to-One Abitur The Abitur Exam Preparation Course offers a total of 34.75 hours of tuition per week, including: - 15 Quatorial hours (4:1) - 10 One-to-One Abitur Tutorial hours (1:1) - 2.5 hours of Project Seminar -

More information

This Agreement is executed by ( Participant ) and, if Participant is under eighteen (18) years of age, by Participant s Parent or Legal Guardian

This Agreement is executed by ( Participant ) and, if Participant is under eighteen (18) years of age, by Participant s Parent or Legal Guardian CUA FIELD HOCKEY CLINIC AGREEMENT AT THE CATHOLIC UNIVERSITY OF AMERICA This Agreement is executed by ( Participant ) and, if Participant is under eighteen (18) years of age, by Participant s Parent or

More information

Prices Prices stated on our price list and internet site are given in Euros, TVA and tourist tax included. Camping sites

Prices Prices stated on our price list and internet site are given in Euros, TVA and tourist tax included. Camping sites 615 route de Sales 74 410 Saint-Jorioz, France + 33 (0) 4 50 68 59 30 contact@campinglesolitaire.com www.campinglesolitaire.com General conditions 2018 Prices Prices stated on our price list and internet

More information

Work Phone. Mobile / / Policy Number Date Issued Number of Travellers. Date of Booking Departure Date Return Date Total Days

Work Phone. Mobile / / Policy Number Date Issued Number of Travellers. Date of Booking Departure Date Return Date Total Days Travel Insurance Claim Form Cancellation You must register any claim within 30 days of completion of your travel. Please supply original documents of the evidence you intend to rely on for your claim,

More information

POLICY /PROCEDURE. Transport Policy. DATE OF ISSUE September DATE OF REVIEW June 2019 VERSION 1. Season Aims and Objectives:

POLICY /PROCEDURE. Transport Policy. DATE OF ISSUE September DATE OF REVIEW June 2019 VERSION 1. Season Aims and Objectives: SECTION POLICY /PROCEDURE Academy Transport Policy DATE OF ISSUE September 2017 DATE OF REVIEW June 2019 VERSION 1 Season 2018-2019 Aims and Objectives: Lincoln City Football Club is committed to safeguarding

More information

Parent & Camper Handbook/Manual

Parent & Camper Handbook/Manual SLAM Sports Summer Camp Parent & Camper Handbook/Manual 2014 SLAM 5 5 5 SLAM 326-0003. SLAM SLAM SLAM Charter schools's d SLAM Academy 25.00 9:00 4 120.00 SLAM 5 5 SLAM SLAM SLAM SLAM main lobby of the.

More information

FRENCH COURSE APPLICATION FORM YEAR ROUND ADULT SCHOOL NORMANDY

FRENCH COURSE APPLICATION FORM YEAR ROUND ADULT SCHOOL NORMANDY EIL Intercultural Learning 1 Empress Place, Summerhill North, Cork, Ireland Tel: +353 (0) 21 4551535 Fax: +353 (0) 21 4551587 info@studyabroad.ie www.studyabroad.ie www.volunteerabroad.ie FRENCH COURSE

More information

American Express Cardmember / Business Travel

American Express Cardmember / Business Travel American Express Cardmember / Business Travel Claim Form The information requested and supporting documents required for your claim are detailed below each section. Further documents or information may

More information

Overseas study protection plan claim

Overseas study protection plan claim Overseas study protection plan claim Important notice If we accept this form, it does not mean we are taking legal responsibility for your claim. If we ask for any documents as proof or a report, you will

More information

WHAT IS AN ELECTRIC COOPERATIVE, AND WHY IS IT GOOD FOR AMERICA AND YOUR COMMUNITY?

WHAT IS AN ELECTRIC COOPERATIVE, AND WHY IS IT GOOD FOR AMERICA AND YOUR COMMUNITY? APPLICATION FORM LEADERSHIP QUESTIONNAIRE Applicant Name: WASHINGTON, D.C. YOUTH TOUR JUNE 7 - JUNE 14, 2018 LIST SPECIAL ACTIVITIES THAT YOU PARTICIPATE IN: WHAT ORGANIZATIONAL OFFICES HAVE YOU HELD?

More information

(US citizens under 18 must apply for the ISP guardianship program) Agent? Yes No Agency Name: Agency Contact Person: Street:

(US citizens under 18 must apply for the ISP guardianship program) Agent? Yes No Agency Name: Agency Contact Person: Street: Last Name (family name) INTERNATIONAL STUDENT PLACEMENTS COLLEGE PROGRAM APPLICATION Attach recent photo here (smiling) Birthdate: Age: Male Female Month / Day / Year (US citizens under 18 must apply for

More information

Overseas Secondment. Claim Form. Important Notes

Overseas Secondment. Claim Form. Important Notes Overseas Secondment Claim Form Important Notes To facilitate the processing of your claim, you are required to complete Sections A, B and C for all claim submissions. The issue and acceptance of this form

More information

Claim for. Death Benefits

Claim for. Death Benefits Notice to readers: This document complies with Québec government standard S G Q R I 0 0 8-0 2 on the accessibility of downloadable documents. If you experience difficulties, please contact us at: 1 800

More information

AIA SINGAPORE AIA ASSIST / AROUND THE WORLD CLAIM FORM

AIA SINGAPORE AIA ASSIST / AROUND THE WORLD CLAIM FORM AIA SINGAPORE AIA ASSIST / AROUND THE WORLD CLAIM FORM This printed form is forwarded on receipt of notice of a claim and its being sent is in no way an admission of claims. PART 1 (TO BE COMPLETED BY

More information

Elite Athlete Strength and Conditioning Camp

Elite Athlete Strength and Conditioning Camp Elite Athlete Strength and Conditioning Camp For your child s safety, and in order to be permitted to participate in all activities, please fill out this form and return it to St. Michael s Summer Camps

More information

2018 CYC Junior Rowing Summer Program Registration

2018 CYC Junior Rowing Summer Program Registration 2018 CYC Junior Rowing Summer Program Registration Rower s Last Name First Name Age/DOB Address City State Zip Code Email Cell School Grade Level (Fall 2018) Parent s Last Name First Name Address City

More information

Summer Camp Application INTERNATIONAL DEVELOPMENT 101

Summer Camp Application INTERNATIONAL DEVELOPMENT 101 INTERNATIONAL DEVELOPMENT 101 Student Information Student Name: Sex : Male / Female Student Preferred/Nickname: Mailing Address: Home Phone Number: Cell Phone Number: School: Grade (Entering): Date of

More information

Claim for Compensation for an Inability to Perform Activities and for Accident-Related Expenses

Claim for Compensation for an Inability to Perform Activities and for Accident-Related Expenses tice to readers: This document complies with Québec government standard S G Q R I 0 0 8-0 2 on the accessibility of downloadable documents. If you experience difficulties, please contact us at: 1 800 3

More information

ATHENS YMCA CAMP KELLEY SUMMER CAMP 2018

ATHENS YMCA CAMP KELLEY SUMMER CAMP 2018 ATHENS YMCA CAMP KELLEY SUMMER CAMP 2018 POLICIES Cost: Full Week (5 Days) $115, Half Week (3 Days) $70; Additional Children: Any additional children will receive a $10 discount on full weeks ONLY. Registration

More information

To enroll your child in our program, please provide the following 4 items:

To enroll your child in our program, please provide the following 4 items: 4211 Waialae Ave #30, Honolulu, HI 96816 Phone: (808) 735-8811 Email: info@bbprekhawaii.com Aloha! Welcome to Bright Beginnings! To enroll your child in our program, please provide the following 4 items:

More information

MANITOBA SOCCER ASSOCIATION POLICIES AND ADMINISTRATIVE PROCEDURES

MANITOBA SOCCER ASSOCIATION POLICIES AND ADMINISTRATIVE PROCEDURES OUT OF PROVINCE GUEST PLAYER RELEASE FORM POLICY STATEMENT: All Manitoba Soccer Association (MSA) players must have approval from the MSA prior to playing for a non-manitoba team. Rationale: The policy

More information

PERSONAL INJURY CLAIM FORM

PERSONAL INJURY CLAIM FORM V-INSURANCE GROUP Corporate Authorised Representative of Willis Office use only Policy Number: 01PO527349 Claim Number: PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR LITTLE ATHLETICS AUSTRALIA V-Insurance

More information

CHAMPAIGN COMMUNITY UNIT SCHOOL DISTRICT NO. 4 Champaign, Illinois FIELD TRIP PERMIT

CHAMPAIGN COMMUNITY UNIT SCHOOL DISTRICT NO. 4 Champaign, Illinois FIELD TRIP PERMIT FIELD TRIP PERMIT (School) (Student s Name) (Teacher/Sponsor) (Telephone Number) PARENTS/GUARDIANS: A field trip to is planned for (class or group) on. The trip will begin at a.m./p.m. and return at a.m./p.m.

More information

EQ TRAVEL CLAIM FORM

EQ TRAVEL CLAIM FORM EQ TRAVEL CLAIM FORM Agency Policy No Please note: Sections 1, 2 and 12 must be completed. Sections 3 to 11 complete only the relevant sections. The acceptance of this form is NOT an admission of liability

More information

PERSONAL ACCIDENT CLAIM FORM

PERSONAL ACCIDENT CLAIM FORM PERSONAL ACCIDENT CLAIM FORM Office Use Only Claim number Reference Complete this form if You have suffered an accident, outside working hours and wish to claim weekly, capital and/or broken bones benefits

More information

Registration Form. Pre School Level : Home Address. Postal Code

Registration Form. Pre School Level : Home Address. Postal Code COURSE PARTICULARS Registration Form Super Wonder Kid Program ( S.W.K.P ) Branch Location : Kovan Tampines Choa Chu Kang S.W.K.P Session / Time : Enterprise One Pasir Ris Woodlands Pre School Level : Explorers

More information

EXTENDED STUDENT SERVICES ASES GRANT AFTER SCHOOL ENRICHMENT PROGRAM (Lakeside Middle School - ASES - LATER Program Only)

EXTENDED STUDENT SERVICES ASES GRANT AFTER SCHOOL ENRICHMENT PROGRAM (Lakeside Middle School - ASES - LATER Program Only) EXTENDED STUDENT SERVICES 2017-2018 ASES GRANT AFTER SCHOOL ENRICHMENT PROGRAM (Lakeside Middle School - ASES - LATER Program Only) Children Registration & Emergency Information (One form per child is

More information

*Plus Cancellation Plan premium, fees and postal charge. ^ Or 50 deposit, whichever is the greater value. Cancellation Plan

*Plus Cancellation Plan premium, fees and postal charge. ^ Or 50 deposit, whichever is the greater value. Cancellation Plan Holiday Bookings - Terms & Conditions December 2018 Please read these conditions carefully. In making a booking you warrant that you are 21 years of age or over and have the authority to accept and do

More information

2016 OUCI Chinese Bridge Summer Camp Application

2016 OUCI Chinese Bridge Summer Camp Application STUDENT INFORMATION Name (as it appears on your passport) Passport # Passport Expiration Date DOB Gender Cell Phone Email Address City State Zip PARENT/GUARDIAN INFORMATION Parent Phone Email Parent Phone

More information

When we receive your claim submission, we will assess it and correspond with you further in due course.

When we receive your claim submission, we will assess it and correspond with you further in due course. Travel Insurance Boots Travel Claims PO Box 60108 London SW20 8US Tel: 0845 125 3820 Fax: 0870 130 1950 Dear Sir / Madam, So that we may process your claim as quickly as possible please ensure that you

More information

REGISTRATION & PERMISSION FORM 2019 ENG4U Ontario Credit course with REACH Cambridge, UK

REGISTRATION & PERMISSION FORM 2019 ENG4U Ontario Credit course with REACH Cambridge, UK REGISTRATION & PERMISSION FORM 2019 ENG4U Ontario Credit course with REACH Cambridge, UK REGISTRATION DEADLINE: March 1, 2019 COURSE DATES: Sunday, June 30 Saturday, July 27, 2019 (four weeks) CONTACT

More information

2018 REGISTRATION FORM - COMPLETED FORM WITH PAYMENT MUST BE RECEIVED BY THE CONTINUING EDUCATION DEPT. FOR STUDENT TO BE REGISTERED FOR CAMP.

2018 REGISTRATION FORM - COMPLETED FORM WITH PAYMENT MUST BE RECEIVED BY THE CONTINUING EDUCATION DEPT. FOR STUDENT TO BE REGISTERED FOR CAMP. Summer Camps 2018 Luzerne County Community College 1333 South Prospect Street, Nanticoke, PA 18634 Tel: 570-740-0495 Fax: 570-740-0491 www.luzerne.edu/coned 2018 REGISTRATION FORM - COMPLETED FORM WITH

More information

Medical Emergency and Associated Expenses

Medical Emergency and Associated Expenses TRAVEL INSURANCE CLAIM FORM Medical Emergency and Associated Expenses You must register any claim within 30 days of completion of your travel. Please supply original documents of the evidence you intend

More information

1.6 Parent/ Guardian": The parent/ guardian of the Student

1.6 Parent/ Guardian: The parent/ guardian of the Student Terms And Conditions The Ingenium Academy Ltd 1. Definitions The following terms shall have the following meanings in this Agreement: 1.1 Academy": the summer school academy run by the company The Ingenium

More information

Dove House Hospice Trek Vietnam 27 th April 7 th May 2019

Dove House Hospice Trek Vietnam 27 th April 7 th May 2019 Dove House Hospice Trek Vietnam 27 th April 7 th May 2019 Please return this completed form, along with your cheque (if applicable) and passport copy to: The Fundraising Team, Dove House Hospice, Chamberlain

More information

Revolutionising Global Student Travel Insurance

Revolutionising Global Student Travel Insurance Revolutionising Global Student Travel Insurance For international students studying in the United Kingdom HealthCare International s Global Student Travel Insurance An insurance policy for international

More information

SPAIN FEDERATION NATIONAL TEAM INTERNATIONAL SOCCER CAMP Terms and Conditions

SPAIN FEDERATION NATIONAL TEAM INTERNATIONAL SOCCER CAMP Terms and Conditions SPAIN FEDERATION NATIONAL TEAM INTERNATIONAL SOCCER CAMP Terms and Conditions Spain Federation National Team International Soccer Camp (RFEF Foundation) strongly recommends the purchase of insurance coverage

More information

Dove House Hospice Indian Himalayas Trek & Project 26 th April 6 th May 2014

Dove House Hospice Indian Himalayas Trek & Project 26 th April 6 th May 2014 Dove House Hospice Indian Himalayas Trek & Project 26 th April 6 th May 2014 Please return this completed form, along with your cheque (if applicable) and passport copy to: Becky Baynes, Dove House Hospice,

More information

Pay4Sure Claim Form. How to complete this claim form

Pay4Sure Claim Form. How to complete this claim form Pay4Sure Claim Form Please read carefully Pay4Sure Claim Form How to complete this claim form Please make sure all sections are fully completed and all documents sent together. Incomplete claim forms or

More information

SUREFIRE BUSHCRAFT

SUREFIRE BUSHCRAFT BUSH CRAFT AND SURVIVAL COURSE INDIVIDUAL DETAILS AND CONSENT TO PARTICIPATION Name inc. Title Course Date Course Fee Home Address Course Title Date of Birth: N.H.S. number Blood Group Have you received

More information

East Carolina University Division of Continuing Studies Summer Study Abroad Program Application

East Carolina University Division of Continuing Studies Summer Study Abroad Program Application GPA Verified East Carolina University Division of Continuing Studies Summer Study Abroad Program Application 2008-2009 Yes Application Instructions: 1. Complete the application forms and attach a $75.00

More information

INSTRUCTIONS FOR COMPLETING THIS UCI LICENCE APPLICATION PRIORITY PROCESSING FEES MTBA / BMXA MEMBERS CHECKLIST

INSTRUCTIONS FOR COMPLETING THIS UCI LICENCE APPLICATION PRIORITY PROCESSING FEES MTBA / BMXA MEMBERS CHECKLIST INSTRUCTIONS FOR COMPLETING THIS UCI LICENCE APPLICATION A UCI licence confirms that the holder undertakes to respect the constitution and regulations of the Union Cycliste Internationale. A UCI licence

More information

Claim for Death Benefits

Claim for Death Benefits tice to readers: This document complies with Québec government standard S G Q R I 0 0 8-0 2 on the accessibility of downloadable documents. If you experience difficulties, please contact us at: 1 800 3

More information

5 easy ways to speed up the claims process

5 easy ways to speed up the claims process Please return your completed claim form to: CignaTTK Health Insurance Company Limited OR Nearest Cigna TTK Branch. Corporate Office: 10th Floor, Commerz, International Business Park, Oberoi Garden City,

More information

Claim Form - Travel Insurance

Claim Form - Travel Insurance Claim Form - Travel Insurance Important tice: To enable us to process your claim, please submit the duly completed claim form with supporting documents in original as listed in the subsequent section.

More information

Saturday June 8th 2013

Saturday June 8th 2013 Saturday June 8th 2013 What kind of skydive will I be doing? A Tandem skydive allows you to enjoy one minute of adrenaline-fuelled freefall from 13,500 feet harnessed to a BPA-qualified instructor; you

More information

PARAMOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIMITED (IRDA License No. 006) [formerly known as PARAMOUNT HEALTH SERVICES (TPA) PVT.

PARAMOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIMITED (IRDA License No. 006) [formerly known as PARAMOUNT HEALTH SERVICES (TPA) PVT. PARAMOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIMITED (IRDA License No. 006) [formerly known as PARAMOUNT HEALTH SERVICES (TPA) PVT.LTD] Plot no.a-442, Road No-28,M.I.D.C Industrial Area, Wagale Estate,

More information

Venue Total Tennis Tennis & English Tennis & BECS* Bradfield College National Tennis Centre Lancing College CAMPS AT BRADFIELD COLLEGE

Venue Total Tennis Tennis & English Tennis & BECS* Bradfield College National Tennis Centre Lancing College CAMPS AT BRADFIELD COLLEGE NIKE Tennis Camps 2016 Booking Form Please complete this form and return to info@edulingo.de Venue Total Tennis Tennis & English Tennis & BECS* Bradfield College National Tennis Centre Lancing College

More information

Travelearn Participant Form

Travelearn Participant Form Travelearn Participant Form Travelearn Program Faculty Coordinator Name Dates of Program This form must be completed in full, and must be accompanied by the following documents: $150 Administrative Fee

More information

TRAVEL INSURANCE (BUSINESS AND HOLIDAY) Claim Form

TRAVEL INSURANCE (BUSINESS AND HOLIDAY) Claim Form SBI General Insurance Company Limited IRDA Reg. No. 144 dated 15/12/2009 CIN: U66000MH2009PLC190546 TRAVEL INSURANCE (BUSINESS AND HOLIDAY) Claim Form Call (Toll Free) 1800 22 1111 1800 102 1111 www.sbigeneral.in

More information

Neptune Water Polo Club REGISTRATION REQUIREMENTS 2012 New & Returning Players:

Neptune Water Polo Club REGISTRATION REQUIREMENTS 2012 New & Returning Players: REGISTRATION REQUIREMENTS 2012 New & Returning Players: 1. Complete the Neptune Water Polo Club Standard of Conduct form. -Signed by parent and player. 2. Complete Neptune Water Polo Club Registration

More information

ECE Travel LTD. Standard Terms and Conditions. with

ECE Travel LTD. Standard Terms and Conditions. with ECE Travel LTD Standard Terms and Conditions with The following booking conditions, together with the information set out on the relevant programme itinerary from ECE will form the contract between your

More information

Travel Arrangements and Expenses Reclaim

Travel Arrangements and Expenses Reclaim 1 Introduction... 1 2 Benefits of using the JACIE travel agent:... 1 3 Travel arrangements... 2 4 Per diem allowance... 3 5 Travel insurance... 4 6 Local travel... 4 7 Use of your own car... 4 8 Rental

More information

Medical Emergency and Associated Expenses

Medical Emergency and Associated Expenses TRAVEL INSURANCE CLAIM FORM Medical Emergency and Associated Expenses You must register any claim within 30 days of completion of your travel. Please supply original documents of the evidence you intend

More information

5 easy ways to speed up the claims process

5 easy ways to speed up the claims process Please return your completed claim form to: CignaTTK Health Insurance Company Limited OR Nearest Cigna TTK Branch. Corporate Office: 401/402, Raheja Titanium, Western Express Highway, Goregaon (East),

More information

Holiday Bookings Terms and Conditions Revised December 2017

Holiday Bookings Terms and Conditions Revised December 2017 Holiday Bookings Terms and Conditions Revised December 2017 1. Please read these conditions carefully. In making a booking you warrant that you are 21 years of age or over and have the authority to accept

More information

VILLA SHAMBALA TERMS & CONDITIONS

VILLA SHAMBALA TERMS & CONDITIONS Revised September 2018 VILLA SHAMBALA TERMS & CONDITIONS TLS Travel Group Limited ( TLS ) acts as an agent for Property owners ( Owner ) and their representatives ( Owner Representative ) in promoting

More information

Get FREE Travel Insurance Coverage with your HSBC Platinum Visa Credit Card

Get FREE Travel Insurance Coverage with your HSBC Platinum Visa Credit Card Get FREE Travel Insurance Coverage with your HSBC Platinum Visa Credit Card As an HSBC Platinum Visa Credit Card holder, you get an exclusive Travel Insurance Coverage when you pay for your travel fares

More information

APPLICATION FORM. Please fill in the white spaces

APPLICATION FORM. Please fill in the white spaces APPLICATION FORM Please fill in the white spaces Mr. / Ms./ Mrs. (NAME) (SURNAME) M F (GENDER) (DATE OF BIRTH) (PLACE OF BIRTH: Country and City) (NATIONALITY) (NATIVE LANGUAGE) (PROFESSION) (ADDRESS,

More information

Please indicate the following:

Please indicate the following: Please indicate the following: Male Church & Denomination (if applicable): Female General Information Surname: Please list your name as it appears on your passport. If you do not yet have your passport,

More information

Title (Mr/Mrs etc) Surname Forename(s) Date of Birth. ' Home Phone. ' Work Phone. ' Mobile / / Policy Number Date Issued Number in Party

Title (Mr/Mrs etc) Surname Forename(s) Date of Birth. ' Home Phone. ' Work Phone. ' Mobile / / Policy Number Date Issued Number in Party TICK Travel Insurance Travel Insurance Claim Form Cancellation You must register any claim within 30 days after completion of your travel. You need to supply to us original documents of the evidence you

More information

PARTICULARS OF POLICYHOLDER / INSURED PERSON / CLAIMANT (to be completed for all claims) NRIC/Passport No.

PARTICULARS OF POLICYHOLDER / INSURED PERSON / CLAIMANT (to be completed for all claims) NRIC/Passport No. Travel Claim Form The acceptance of this Form is NOT an admission of liability on the part of HL Assurance Pte. Ltd.. Any documentary proof or report required by HL Assurance Pte. Ltd. shall be furnished

More information

PROVENCE ESCAPE REGISTRATION

PROVENCE ESCAPE REGISTRATION PAGE 1 / 6 PROVENCE ESCAPE REGISTRATION First, middle & last name Street City, ZIP & country E-mail Mobile phone Date of birth I herewith make a binding registration to take part in THE PROVENCE ESCAPE

More information

Income Travel Claim Submission Procedure

Income Travel Claim Submission Procedure Income Travel Claim Submission Procedure Step 1 - Print the claim form. Step 2 - Complete the claim form and refer to the claim matrix for supporting documents required. Step 3 - Get the authorized personnel

More information

HDFC ERGO General Insurance Company Limited

HDFC ERGO General Insurance Company Limited HDFC ERGO General Insurance Company Limited Overseas Travel Insurance Claim Form (To be filled in by the Insured Policyholder or Insured s Representative duly authorised by Power of Attorney. Issuance

More information

19 th December Dear Parents/Carers YEAR 8 VISIT TO FRANCE MONDAY, 16 TH JULY TO FRIDAY, 20 TH JULY 2018

19 th December Dear Parents/Carers YEAR 8 VISIT TO FRANCE MONDAY, 16 TH JULY TO FRIDAY, 20 TH JULY 2018 19 th December 2016 Dear Parents/Carers YEAR 8 VISIT TO FRANCE MONDAY, 16 TH JULY TO FRIDAY, 20 TH JULY 2018 Following the success of previous Year 8 visits to France and Germany, it has been decided to

More information

Session I and Session II Session I: June 5 June 9, Performance June 10th; Hollydale United Methodist Church

Session I and Session II Session I: June 5 June 9, Performance June 10th; Hollydale United Methodist Church th Session I and Session II Session I: June 5 June 9, Performance June 10th; Hollydale United Methodist Church Session II: June 12th - June 16th, Performance June 13th; Music On Wheels Academy Music Camp

More information

SURFING PERSIA Booking Terms & Conditions

SURFING PERSIA Booking Terms & Conditions SURFING PERSIA Booking Terms & Conditions Thank you for booking and travelling on with SURFING PERSIA. These Terms and Conditions apply to any travel products and services purchased from SURFING PERSIA,

More information

Keowee Sailing Club Sailing Camp Application

Keowee Sailing Club Sailing Camp Application Keowee Sailing Club Sailing Camp Application I/we hereby apply for the below named camper to participate in the Sailing Camp to be held at Keowee Sailing Club, Seneca, SC, June, 2017. Campers should arrive

More information

FACULTY-LED STUDY ABROAD PROGRAM APPLICATION

FACULTY-LED STUDY ABROAD PROGRAM APPLICATION FACULTY-LED STUDY ABROAD PROGRAM APPLICATION Country of Study: Dates of Travel: I. PARTICIPANT INFORMATION Name: Street Address: City: State: Zip Code: Date of Birth: Passport #: Country of Citizenship:

More information

CLAIM FORM FOR MEDICAL EXPENSES AND OTHER EXPENSES

CLAIM FORM FOR MEDICAL EXPENSES AND OTHER EXPENSES CLAIM FORM FOR MEDICAL EXPENSES AND OTHER EXPENSES Please note that we have to ensure that our claim form covers all types of claim. If you do not consider a question to be relevant to your circumstances

More information

SUBJET: REIMBURSMENT COMPENSATION FORM

SUBJET: REIMBURSMENT COMPENSATION FORM FILE NUMBER: Mr./Ms. SUBJET: REIMBURSMENT COMPENSATION FORM Dear Insured, IN CASE OF APPLICATIONS FOR REIMBURSEMENT: All documentation should be sent to: 1. Option: if your original documents are electronic

More information

RENTAL TERMS AND CONDITIONS

RENTAL TERMS AND CONDITIONS RENTAL TERMS AND CONDITIONS The Luxe Nomad ( TLN ) acts as an agent for Property owners ( Owner ) and their representatives ( Owner Representative ) in promoting Properties for rent and arranging bookings.

More information

abcd Student Handbook 2018 for Young Learners and Teenagers (Age group 10 to 16 years)

abcd Student Handbook 2018 for Young Learners and Teenagers (Age group 10 to 16 years) abcd Student Handbook 2018 for Young Learners and Teenagers (Age group 10 to 16 years) Contents Page Checklist before and on departure... 3 Travel Documents... 4 Travel Information... 5 Transfer Services

More information

OHIO CAMPus REC Summer Camp

OHIO CAMPus REC Summer Camp OHIO CAMPus REC Summer Camp AGREEMENT AND RELEASE OF LIABILITY FORM This release executed by the Undersigned on behalf of [Name of Participant] with an address at ( Participant ) to Ohio University, Athens,

More information

PERSONAL INJURY CLAIM FORM

PERSONAL INJURY CLAIM FORM Office use only Policy Number: AN A038364 PAD Claim Number: PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR TRIATHLON AUSTRALIA V-Insurance Group Pty Ltd Level 4, 179 Elizabeth Street, SYDNEY NSW 2000

More information

AUSTRALIAN CANOEING NATIONAL INSURANCE PROGRAM

AUSTRALIAN CANOEING NATIONAL INSURANCE PROGRAM Office use only Policy Number: Claim Number:. AUSTRALIAN CANOEING NATIONAL INSURANCE PROGRAM PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR AUSTRALIAN CANOEING; V-Insurance Group Pty Ltd Authorised Representative

More information

St Richard s Hospice Nepal Himalaya Trek and Hospice Project 2 nd 13 th November 2019

St Richard s Hospice Nepal Himalaya Trek and Hospice Project 2 nd 13 th November 2019 St Richard s Hospice Nepal Himalaya Trek and Hospice Project 2 nd 13 th November 2019 Please return this completed form, along with your cheque (if applicable) and passport copy to: Fundraising, St Richard's

More information

CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT PART A

CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT PART A SBI General Insurance Company Limited CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT PART A TO BE FILLED IN BY THE INSURED The issue of this Form is not to be taken as

More information

Flinders University AUS Participant Agreement Form 2017

Flinders University AUS Participant Agreement Form 2017 Flinders University AUS Participant Agreement Form 2017 This agreement is completed in addition to the Australian University Sport event participation agreement. Please read it carefully and sign as appropriate

More information

When we receive your claim submission, we will assess it and correspond with you further in due course.

When we receive your claim submission, we will assess it and correspond with you further in due course. Travel Insurance Boots Travel Claims PO Box 60108 London SW20 8US Tel: 0845 125 3820 Fax: 0870 130 1950 Dear Sir / Madam, So that we may process your claim as quickly as possible please ensure that you

More information

PART 2: Payer s Details PLEASE COMPLETE ALL FIELDS IN BLOCK LETTERS

PART 2: Payer s Details PLEASE COMPLETE ALL FIELDS IN BLOCK LETTERS STUDENT PICTURE CONTACT DETAILS PART 1: Student Details PLEASE COMPLETE ALL FIELDS IN BLOCK LETTERS NB: Full time and Part Time Students to fill in Part 1,2,3,4,5 NB: E-Learning Students to fill in Part

More information

East High Rugby Sooner State Tour II Friday April 6 Monday April 9

East High Rugby Sooner State Tour II Friday April 6 Monday April 9 East High Rugby Sooner State Tour II Friday April 6 Monday April 9 All East High Rugby players are encouraged to travel with the team to matches in Tulsa, Oklahoma. The 22 nd annual tour is a great team

More information

EKU Educational Talent Search Program DECEMBER 2018 SPECIAL EVENTS Saturday, December 1, 2018 Lexington Ice Center/ Triangle Park Winter Ice Village Rink 9:00 am Students arrive at EKU Perkins Bldg. for

More information

ECO- ADVENTURE COZUMEL, MEXICO 2018 Important Registration Material- Please Read

ECO- ADVENTURE COZUMEL, MEXICO 2018 Important Registration Material- Please Read ECO- ADVENTURE COZUMEL, MEXICO 2018 Important Registration Material- Please Read Camp Description Students must be entering or have completed 9 th grade to be eligible for this program. Camp dates: June

More information

Any fee charged by the member s GP for providing information for completion of the claim form will not be covered.

Any fee charged by the member s GP for providing information for completion of the claim form will not be covered. TRAVEL COVER CLAIM FORM FILLING IN THIS FORM Please fill in this form if a claim is being made from the Worldwide Travel Cover. Complete this form in black ink and as fully and truthfully as possible.

More information

Cassis to Monaco Participant Registration Form 5 7 October 2018

Cassis to Monaco Participant Registration Form 5 7 October 2018 Cassis to Monaco Participant Registration Form 5 7 October 2018 Participation in the Cassis to Monaco cycle includes: Twin share hotel accommodation on the evenings of 5 th to 7 th October 2018. Single

More information