Moate Community School Student Application Form

International Student Application Form
Full Name

First Name Last Name
Date of Birth
Nationality
Irish Agency
Host Family Name

First Name Last Name
Host Family Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number of Host Family

Area Code Phone Number
Enrolment into

1st year 2nd year 3rd year TY 5th year 6th year
Length of Stay

Full year September to Christmas September to Midterm
Please attach a most recent School report and reference from the school
Additional Information/Requests
School report
Reference
A deposit of €200 is required to secure school placement
Deposit Sent

Yes No
Communications should only be done through a Host Family or Agency
Please post the deposit to Maura Murray, Deputy Principal, Moate Community School, Church St., Moate , Co Westmeath, Ireland
Enrolled by
E-mail
Date

Month Day Year
Should be Empty:

International Student Application Form