ICON Guardianship Application Form - Icon Education

ICON Guardianship Application Form - Icon Education

enquiry@iconedu.co.uk +44(0)115 850 0388
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By completing this form below, you, the parents/legal guardians of the child named below, hereby appoint ICON Guardianship to provide education guardianship services while they are studying in the United Kingdom. Once we receive your application form, an Educational Guardian will contact you with confirmation paperwork

Student Details

Family Name(s)*

First Name*

Preferred Name*

Date of Birth*



Student Mobile Number

Student Email

Special interests / Hobbies

School/University Details

Guardianship Type*

Family Details

Mothers Name*

Fathers Name*


Parent Mobile Number


Emergency Number (This can be telephone number of a relative)

Parent 1 Email*

Parent 2 Email

Other Email

Details about your family

Please tell us something about yourself and your family that you would like us to include in your child's student profile, we will send this to the host family.

Agent Details (if applicable)

Agent Name

Agent Email

Contact Correspondence

Person 1 to contact for all correspondence*

Person 2 to contact for all correspondence.(if applicable)

Passport Number

Passport Expiry Date

Visa / Biometric Residency Permit Number

Visa / Biometric Residency Expiry Date

Your Consent

Medical emergencies:
If you cannot be contacted, do you consent to all emergency medical or dental treatment including inoculations, general or local anaesthetic, surgery or blood transfusions which, in the opinion of a qualified doctor, are necessary for your child's safety and well-being, under the National Health Service or privately if necessary?YesNo

Minor Ailments:
Do you consent to the administration of medication such as paracetamol, cough mixture, eye drops etc normally sold over the counter by a chemist for treatment of minor ailments (always taking into account medical information you have supplied to the guardian)YesNo

Do you consent to your child travelling by any form of public transport and/or in a motor vehicle driven by a responsible adult who is duly licensed and insured to drive a vehicle of that type?YesNo

Do you consent to your child swimming under adult supervision?YesNo

All other activities
Do you consent to your child taking part, under adult supervision, in water sports & fairground rides?YesNo

Please list any specific activities in which you do not consent to your child taking part

Does the student have any allergies or intolerances? (e.g. medication/food/dust/stings):YesNo

Does your child suffers from any medical or psychological conditions that may require them to have additional levels of support from the host family?:YesNo

Notes: If you answer yes to this question it does not mean we will not accept your child, simply that we need more information to ensure that we have suitable families to meet your child's safeguarding needs. We will send you a Medical Information form for you to complete before we will review the application and consider if we are able to accept your enrolment.

How Did You Hear About ICON?

We have read and understood the Icon Guardianships Ltd terms and conditions. We will pay the fees in advance or on receipt of an invoice.

We have read and we understand and accept the contents of the documents referred to in the terms and conditions which explain the scope of the guardianship responsibilities and services