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2014 - 2015 APPLICATION FORM

First Name:
Male

Last Name:
Date Of Birth (Day/Month/Year) :

Female

Nationality:

What languages do you speak?

Your Level of English:

E-Mail:

Beginner

Intermediate

Upper Intermediate

Current Address in Canada or in your country: Country

Advanced

City

Postal Code:

Facebook:

Street and Number

Telephone (+ area and country code):

Status in Canada:

Visitor

Medical Insurance Required?

Cel:
Student

Working Holiday
No

Yes

Other (Specify)

If your answer is YES, specify number of days and start date of insurance:

Emergency Contact: Name:

Telephone (Including area and country code)

How did you hear about inlingua?

(Select all the options that apply to you)

Google

Friends

Brochure

Facebook

Fair / Show

Other (Specify)

Agency (Please specify Agency and Counsellor Name)

Course(s) Applied for

IP1-Intensive

SE-Star English

ACP - Accelerated
Communication program

PT1-Part Time

SE Aft.

UPP - University

Private lessons #____

Business English

Cambridge FCE

Cambridge CAE

TOEFL iBT

IELTS

Voluntern

Farmstay Experience

Preparation program

Course 1 Start Date (Day/Month/Year)

Course 1 End Date (Day/Month/Year)

Total Weeks:

Course 2 Start Date (Day/Month/Year)

Course 2 End Date (Day/Month/Year)

Total Weeks:

Course 3 Start Date (Day/Month/Year)

Course 3 End Date (Day/Month/Year)

Total Weeks:

Yes

Do you have any physical or mental health problems ?

No

If your answer is YES, specify:

Do you want accommodation?

Yes

No

If your answer is YES, please complete Form #2

Do you want airport reception?

Yes

No

Airport drop off?

Accommodation Type:

Yes

Homestay (Half Board 2 meals)

Homestay (Full Board 3 meals)

Accommodation Start Date (Day/Month/Year):

If your answer is YES, please

No complete Form #3

Accommodation Information Form #2

Rooming (no meals)

Student House

(shared room,
no meals, 19 +)

Accommodation End Day (Day/Month/Year)*

* NOTE: If you will stay for more than 4 weeks in Vancouver and you are NOT sure if you want to stay in the homestay / rooming / student house for more than the first
4 weeks, please write down the end date of your course here. Failure to do so may result in additional accommodation placement fees.
NOTE: Students will pay the accommodation fee and the First 4 weeks of accommodation ONLY. Additional 4-week periods will be paid at inlingua, in advance.
What are your interests / Comments
Do you take any medication?

Yes

No

If your answer is YES, specify:

Do you have any allergies?

Yes

No

If your answer is YES, specify:

Are you a vegetarian / special diet?

Yes

No

If your answer is YES, specify:

Do you smoke?

Yes

No

Would you live with a family with Young Children?

Would you live with a family with Teenagers?
Homestay Special Requests

Additional charges apply - subject to availability -

Yes

No

Yes

No

Private Bathroom
100 every 4 weeks

Would you live with a family with Smokers?

Yes

No

Would you live with a family with Dogs?

Yes

No

Would you live with a family with Cats?

Yes

No

Closer to School

50 every 4 weeks

Private TV

25 every 4 weeks

These requests are subject to availability, only for homestay,

for students 17 years old and more. Not possible in rooming
or in the student house.

Arrival Information Form #3

Date of arrival (Day/Month/Year):

Time (24 Hour time format):

Name of airline:

Connecting city:

(if unknown, please leave empty)

Flight No:

DECLARATION: I HAVE READ AND UNDERSTOOD AND I AGREE TO BE BOUND BY THE SCHOOL'S POLICIES ON ADMISSIONS, ACCOMMODATION, DISPUTE
RESOLUTION, DISMISSAL, VACATIONS AND REFUNDS. I ALSO PROMISE TO RESPECT THE ENGLISH ONLY POLICY AT ALL TIMES.
Date:

Student Signature

parent or guardian if minor

Agent Signature
if applicable