Please print out, sign and return to Learn Overseas Ltd

If you are under 18years of age we will need your parent/guardians consent or the application will be invalid.

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I hereby give my consent to the below named persons application for a two-week work-experience placement in hospitals / clinics in India.

I have read and agree with the terms & conditions.

Student Details
First Name:	*
Surname:	*
Telephone no:	*
Email address	*
Home Address	*
Post Code

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Parents / Guardians Details
Relationship to student
Title
First Name
Family Name
Address
Post Code
Home Tel Number
Mobile/Cellphone No
Work Tel Number
E-mail:
Any information you would like to add

Signature:	______________________________
Date:	______________________________