Mr Mrs Ms Mr / Mrs / Ms

Family Name

First Name(s)

Date of birth

male female Sex

Nationality

Mother tongue

Address (street, no.)

Postal code

City

Country

Telephone

Fax

E-Mail

total beginner beginner elementary intermediate upper intermediate advanced Knowledge of German

Study of German in years

Profession (for pupils: profession of parents)

Personal interests or hobbies

yes no Allergies

Remarks concerning your state of health

yes no Smoker

Courses at school

- Freiburg Horb am Neckar Tuebingen Stuttgart Munich Augsburg Cologne Course centre

Course type

Course number

Special course type: German at a teacher's home

- Region Stuttgart Region Tuebingen Region Black Forest Region Duesseldorf Region

Course date, from - to

Number of weeks

Lessons per week

Accommodation: Host family, from - to

Accomoodation: Residence (where possible), from - to

no transfers on arrival on arrival and return Do you want transfer(s)?

Price in € for transfer(s)

Total price in €

I confirm my acceptance of the General Conditions of Participation (see Complete Programme 2009 page 14/15) and I confirm that the above details are correct.

We strongly advise that you take out medical, travel and course insurance:

I would like Glinka-Sprachreisen to arrange insurance for me

I will arrange my own insurance (please bring a copy of your insurance cover)

Place, date