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    STUDENT DETAILS

    First Name
    Last Name

    Date of Birth

    Age

    Gender

    School Name

    Year

    Current Level (English)
    Current Level (Maths)
    Current Level (Science)

    CIRCUMSTANCES RELATING TO YOUR CHILD (Please tick boxes as appropriate)

    Others - Pleaes specify

    DETAILS OF ADULT MAKING THE APPLICATION (primary contact for all correspondence)

    Title

    First Name

    Last Name

    Address1

    Address2

    Postcode

    Phone

    Mobile

    Relation to Student

    Email

    Occupation

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