IPSA - International Partners for Study Abroad 

                       
Application
                   
to Study Abroad and Spanish Learning Center

at the Universidad Católica de Valparaíso, Chile

                Please print out this form from your browser, 
                complete (print or type) and sign the Apllication 
                               and send it by mail to:

                             IPSA Enrollment Center 
                               40240 N. 69th Place
                               Cave Creek, AZ 85331, USA 

                               or by Fax to: +1 (602) 942-6734


Part A. Personal data:

First Name: ___________________  Last Name:  ______________________________

Home Address: _____________________________________________________________

___________________________________________________________________________

Telephone: (____)________________  Fax: [optional] (____)__________________

E-mail: [optional] ________________________________________________________

Date of Birth: (month/day/year) _____/____/___________    __ Male  __Female

Place of Birth (country, city):  __________________________________________

Nationality:  _________________  Citizenship (country): ___________________

Native language: __________________

Other languages, if any: __________________________________________________

    I am a college    __ freshman    __ sophomore    __ junior    __ senior

    __ Graduate Student    __ High School Senior        __ Interested Adult

    __ Professional.  Please enter your profession: _______________________

If you are a graduate or undergraduate student, please provide the 
following information: 

Current college/university/graduate school:  ______________________________

___________________________________________________________________________

Major field of study: _____________________________________________________

Address of your college, university: ______________________________________

___________________________________________________________________________


Insurance:

It is advisable that students have health insurance while residing or 
traveling in Chile. The insurance carrier in the student's home 
country can provide this coverage.

My insurance company is:  _________________________________________________ 
 
Policy Number: ____________________________________________________________ 


Emergency Contact:

   Name:   ________________________________________________________________

   Relationship:______________________  Telephone: ________________________
 
   Address:   _____________________________________________________________



Part B. Program data:


I want to register for the following program: (Please check a program below) 

__Calendar Year Program (January - December)

__Academic Year Program (February - December)

__Academic Year Program (July to July)

__First Semester Program (February - July)
 
__Second Semester Program (July - December)

Please describe your educational goals and indicate courses you would like 
to study at the Universidad Católica de Valparaíso:

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

__January Open Spanish Program
  
__Summer I Open Spanish Program

__Summer II Open Spanish Program


__Individual One-to-one course

  I Wish to Start my course on ___(Day) __________(Month)  ______(Year)

  I want to attend the course for ____ weeks

  I want to register for ____ one-to-one lessons per week


Comments: __________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________
  
   
Have you studied Spanish before?      __Yes      __No  
If yes, where:

____________________________________________________________________________
(type of school e.g. high school, university, private language school)    

For how long: ______________________________________________________________  

What is your present level of Spanish? 

__Beginner   __Elementary   __Intermediate  __Upper-intermediate  __Advanced

 
Which areas would you most like to improve: 

__Speaking  __Understanding  __Listening  __Reading  __Writing  __Vocabulary 

____________________________________________________________________________


Accommodations:

Do you need accommodation with a Chilean family?  ___Yes. __No.

If yes, please answer the following questions to help us find a homestay that 
is right for you: 

Do you smoke? __Yes  __No       Do you like pets? __Yes __No
  
Do you like children? __Yes   __No  

Do you have allergies to food/animals? List: _______________________________

____________________________________________________________________________
  
Please enter below your accommodation requirements (if any):

____________________________________________________________________________

____________________________________________________________________________ 

 
Accomodation Arrival date: ________________  Checkout date: ________________

Do you require airport pickup?   ___Yes  __No

**Arrival date: ____________________________   **Time: _____________________  

**Airline _________________________   **Flight Number: _____________________
 
**Without this information, airport pickup services can not be guaranteed. 


Part C. Payment of Fees:
 
Please note that your application will be considered only when your payment 
of the Application Fee ($150) and deposit ($300) has been received.

All payments must be made in U.S. dollars and payable through U.S. banks. 
Any collection charges will be the applicant's responsibility. Checks or 
international money orders drawn on foreign banks will not be accepted. 

Please select one of the following payment options: 


1. __Please find enclosed a certified check/money order for the application
     fee and the tuition deposit.

Cashiers Checks or international money orders must be made payable to IPSA. 

Please send a check or international money order with your application to:

IPSA
40240 N. 69th Place
Cave Creek, AZ 85331, USA


2. International Wire Transfers

You can make your payment by wire transfer. Just fax us your application 
and request our account and bank information:

___I want to pay the application fee and the tuition deposit by wire transfer.
   Please send me instructions on  how  to  send  the  wire  transfer to your 
   bank account.


3. Payment by Credit Card: 

Please select credit card:  ___VISA    ___MasterCard

Credit Card No: _____________________ Expiration Date: Month ____ Year_____

Card Verification Value: ___________  (The last three digits on the back of 
your credit card after the credit card number.)


Cardholder Name: __________________________________________________________

Street Address:  __________________________________________________________

City:______________________   State:___________________ Zip Code:__________


I authorize to charge the above credit card account:

___ application fee and deposit   ___ application fee and full payment due

Even if you select a "full payment" option, we will charge the application
fee and the tuition deposit at the time of  accepting your application and 
will process the payment of the  balance  to your  credit card  only after 
registering you for the course.  Please also note that if you would prefer 
to pay the balance by credit card, a  4.5% payment processing  service fee 
will be included in the invoice.
      

Comments: _________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________


Part D. Agreement and release.

By signing this Application, I certify the above information is complete and 
correct. I understand  that  my misrepresentation may result in my expulsion 
from the program. I  acknowledge  that the terms and conditions appearing on 
the web  site  constitute  part  of  my agreement with IPSA and study abroad 
program host (university, college, language school, or other institution and
or  organization),  including  sections  concerning  responsibility, health, 
refunds,  changes  in  dates,  accommodations,  courses  and  billing of the  
selected options. I have read the Agreement and agree to follow all IPSA and  
study  abroad  host  procedures.  This Agreement  will  be effective when my  
application  is  accepted  by IPSA  and shall be governed by the laws of the 
State of Arizona, USA. 



Applicant's Signature ______________________       Date: ___________________


Parent's/Legal Gardian's  
Signature if applicant  
is under 18 years     ______________________       Date: __________________




Please do not forget to make a copy of this completed and signed application
for your records and enclose your payment of the application fee and deposits.