Student's full name (as shown on passport):

Preferred English name (if so desired):

Male/female:

Date of birth:

Home address:

Country of citizenship:

Ethnic group:

Religion:

First language:

Previous English language tuition:

Intended date of arrival to New Zealand:

Passport Number:

Intended length of time to study at St Pius X School:

Will there be an accompanying adult travelling with you?:

If so, name and relationship to student:

Full name of Father:

Occupation:

Full name of Mother:

Occupation:

Full postal address:

Home phone:

Work phone:

Facsimile:

Email:

Name of Company:

Agent's full name:

Full postal address:

Phone: