I, hereby certify that the above information is true and complete. I understand that any false or incomplete information
2018 ENGLISH IN CANADA
REGISTRATION FORM STUDENT INFORMATION Mr.
❏
Ms.
❏
Nationality: ______________________________
Mother Tongue: ____________________________
Passport # ________________________________
Last Name: ________________________________________ First Name: ________________________________________
Date of Birth: ______________________________
(AS APPEARS ON PASSPORT)
(AS APPEARS ON PASSPORT)
Home Address: _______________________________________________________________ City: __________________ Country: ___________________________
Province: ___________________________________ Postal Code: ___________________________________
Email: _______________________________________________________
Emergency Contact Person: _______________________________________________________ AGENT INFORMATION
Agency: _______________________
PROGRAM DETAILS
SCHOOL LOCATION
❏
Telephone: _______________________________
Emergency Contact Phone: ___________________________
Contact Person: ________________________
Toronto
YYYY / MM / DD
Vancouver
Email: ___________________________________
❏
PROGRAM INTENSITY
❏
Intensive English (30 lessons/week)
❏
Power English (38 lessons/week)
Start Date: ___________________________________ YYYY / MM / DD
Weeks of Study ___________________________________
COURSE FOCUS
You have the option to change this course every second week.
❏ ❏
General English Business English
❏ ❏
Cambridge English (FCE) Cambridge English (CAE)
❏ ❏
TOEFL Preparation
❏
IELTS Preparation
Other _________________________________
The University Pathway Program
AIRPORT TRANSFER Arrival Date: ________________________________ YYYY / MM / DD
Flight Information ________________________________
Airport Pick-up
Yes
❏
No
❏
Flight Information ________________________________
Airport Drop-off
Yes
❏
No
❏
(if available)
Departure Date: ___________________________ YYYY / MM / DD
(if available)
ACCOMODATION
❏ Single Homestay ❏ Twin Homestay ❏ Residence* (On Request)
(On Request)
❏ No Accommodation
Length Weeks
Special Request or Preferences
ILAC will do its best to accommodate your requests, however, due to availability ILAC cannot guarantee that your request will be granted.
Specify Residence*
Residence is available upon request, please email at
[email protected]
MEDICAL INFORMATION Do you have Medical Insurance? If No, would you like to book insurance through ILAC? Do you have any allergies?
Do you have any medical problems or physical disability? Do you have any food restrictions? Are you allergic to pets? Do you smoke ?
*Please note: It is mandatory for ILAC students to have Medical Insurance during their stay in Canada.
❏ Yes ❏ Yes ❏ Yes ❏ Yes ❏ Yes ❏ Yes ❏ Yes
❏ No ❏ No ❏ No ❏ No ❏ No ❏ No ❏ No
Policy Number: ____________ Start Date: _______________________ End Date: _______________________ YYYY/ MM / DD
YYYY/ MM / DD
List of Allergies _______________________________________________________ List Medical Issues or Physical Disability: __________________________________ List Food Restriction: ___________________________________________________ List any other issues: ___________________________________________________
I, hereby certify that the above information is true and complete. I understand that any false or incomplete information submitted in support of my registration may invalidate my registration. I agree to speak only English on School property. I have read and understand all of ILAC policies & procedures including the Tuition Refund Policy and the Dispute Resolution Policy. (available on ilac.com/policies).
Applicant signature: _______________________
Co-applicant signature _______________________________________________ ilac.com/
[email protected]
Date: _______________________________ YYYY / MM / DD
