Cúrsaí Samhraidh Gaeltachta (Daoine Óga) – Machaire an Rabhartaigh Order Number Cúrsaí? Cúrsaí? Cúrsaí A – 19.06.20 – 04.07.20 Cúrsaí B – 05.07.20 – 26.07.20 Cúrsaí C – 27.07.20 – 18.08.20 Sloinne an Dalta/Student’s Surname * Céadainm(neacha) an Dalta /Student’s Forename(s) * Inscne | Sex * Buachaill/Boy Cailín/Girl Dáta Breithe/Date of Birth * Teileafón Póca an Dalta/Student’s Mobile Telephone Number * Ainm/Name of parent or Guardian * Seoladh na Scoile 1 * Seoladh na Scoile 2 Seoladh na Scoile 3 Contae * Contae Aontroim Ard Mhaca BÁC An Cábhán Ceatharlach Ciarraí Cill Chainnigh Cill Dara Cill Mhantáin An Clár Corcaigh Doire An Dún Dún na nGall Fear Manach Gaillimh An t-Iarmhí Laois Liatroim Loch Garman Longfort An Lú Luimneach Maigh Eo An Mhí Muineachán Port Láirge Ros Comáin Sligeach Tiobraid Árainn Tír Eoghain Uíbh Fháilí Eircód | Postcode Teileafón Baile/Home Telephone Mobile Number of Parent/Guardian * Seoladh Ríomhphoist/Email Address of Parent or Guardian * PLEASE DOUBLE CHECK THIS ADDRESS as this address will be the main point of contact regarding this booking from now on. Emergency Contact Name * Name and phone number of the person responsible for the student in the event of the parent/guardian not being available during the course Emergency Contact Home Number Emergency Contact Mobile Number Scoil faoi Láthair – Ainm agus Seoladh/Current School – Name and Address Scoil faoi Láthair – Ainm * Seoladh na Scoile 1 (Scoil faoi Láthair) * Seoladh na Scoile 2 (Scoil faoi Láthair) Seoladh na Scoile 3 (Scoil faoi Láthair) Contae (Scoil faoi Láthair) * Contae Aontroim Ard Mhaca BÁC An Cábhán Ceatharlach Ciarraí Cill Chainnigh Cill Dara Cill Mhantáin An Clár Corcaigh Doire An Dún Dún na nGall Fear Manach Gaillimh An t-Iarmhí Laois Liatroim Loch Garman Longfort An Lú Luimneach Maigh Eo An Mhí Muineachán Port Láirge Ros Comáin Sligeach Tiobraid Árainn Tír Eoghain Uíbh Fháilí Eircód | Postcode (Scoil faoi Láthair) Rang/Bliain – Class/Year * Múinteoir Gaeilge * Name of Family Doctor Each Student must bring a photocopy of European Health Insurance Card Telephone Number of Family Doctor * Medical Card Number Special Medical and Dietary Requirements – In the case of any medical condition affecting the student or if the student requires a specific diet, please include all relevant details here Has the student received both MMR and Meningococcal C Vaccinations? * Tá/Yes Níl/No Tugaim cead don Choláiste ligean do mo pháiste paraicéiteamól a ghlacadh faoi mhaoirseacht, más gá. * Tugaim/I do Ní thugaim/I do not I authorise the College to allow my child to take paracetamol under supervision, if required. Swimming Ability * Ní Féidir/Cannot Tosaitheoir/Beginner Meán/Intermediate Ardleibhéal/Advanced Ainmnigh cara amháin ar mhaith leat a bheith sa teach céanna leat. Name one friend with whom you wish to share. Gael Linn cannot guarantee that students will be housed together. Please note that this friend must also have this student on their form. An bhfuil sé i gceist agat leas a bhaint as socruithe taistil bus eagraithe ag Gael Linn? * Tá/Yes Níl/No Do you intend to avail of bus service organised by Gael Linn If YES please indicate the nearest town to where you live Don Tuismitheoir agus don Dalta/For the Parent and the Student Modh Íocaíochta – Payment Method * Select Payment Method Íoc le cárta Íocaíocht leictreonach I gCuntas bainc Gael Linn (EFT) Íoc Le Seic Stripe total Total:
