IPSA - International Partners for Study Abroad
Application
to Spanish Language School in Cusco, Peru.
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
Application Deadlines
Normally, we must receive a complete set of application
documents and fees no later than 30 days before the program starts.
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: ______________________________________
___________________________________________________________________________
Emergency Contact:
Name: ________________________________________________________________
Relationship:______________________ Telephone: ________________________
Address: _____________________________________________________________
Part B. Program data:
I Wish to Start Classes on ___(Day) _____________ (Mo) ______(Year)
For how many weeks do you want to register: ____Number of weeks
Which course would you like to study?
__Standard Group course (4 hours per day)
__Individual one-to-one (4 hours per day)
__Best of Both (4 hours group and 2 individual per day)
__Additional Individual Classes:
If you would like to take additional individual classes,
please enter the number of additional individual classes per day: ____
__I also want to spend __weeks in Urubamba
__I also want to spend __weeks in Manu
Special Spanish Courses:
__Total immersion
__Spanish for Medical Purposes
__Spanish for 55+:
__Spanish for University Students
__Semester Study Abroad Program
Spanish and Peruvian Culture
(Please also select one of the Spanish language courses)
__Inca Civilisation
__Christmas Course
__Quechua
__Peruvian Cultural Workshop Program
Spanish Plus Volunteer Program
__Standard Volunteer Program (4 + 4)
__Volunteer Plus Program (8 + 8)
__All in One: Spanish, Excursions and Volunteering (3 weeks)
When booking the volunteer work and language study package, we'll ask you
to indicate your first, second and third preferences for project placement:
1st preference: __________________________________________________________
2nd preference: __________________________________________________________
3rd preference: __________________________________________________________
___________________________________________________________________________
You'll also need to send your resume and a letter (in Spanish) telling us
about your motivations for participation in our Volunteer programs.
What is your present level of Spanish?
__Beginner __Elementary __Low Intermediate __Intermediate __Advanced
__Spanish for the Whole Family
Comments:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Accomodations:
Please select the accommodations you prefer:
__Host family accommodation single room, full board
__Host Family Plus accommodation
Student Residence: __Single room __Double Room
Please also fill in below:
Are you a smoker? __yes __no
If you have a special diet, please specify:
___________________________________________________________________________
If you have allergies, please specify:
___________________________________________________________________________
If you have other requirements, please specify:
___________________________________________________________________________
___________________________________________________________________________
Do you require airport pick-up service package from Lima to Cusco?
__Yes. __No.
Please provide us with your flight arrival information in Lima if you
require airport pick-up service package from Lima to Cusco, or with your
flight arrival information in Cusco, if you do not require airport pick-up
service package from Lima to Cusco. Pick-up service in Cusco is free.
Arrival date: _______________________ Arrival Time: ______________________
Airline and Flight Number: ________________________________________________
Departure City: ___________________________________________________________
Part C. Payment of Fees:
Please note that your application will be considered only when your payment
of the non-refundable Application Fee of $80.00 and the Tuition Deposit of
$200.00 has been received.
Please also note: we must receive a full payment at least 30 days before
the commencement of your program.
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 Study Abroad International 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 assume all risks and responsibilities
and discharge IPSA and the study abroad program host and all their officers,
agents and employees from and against any and all claims of damage to
personal property or personal injury which may result from my enrollment and
participation in the study abroad program host courses, excursions, and/or
on and off-campus activities. I have read all terms and conditiones and
rules and agree to follow all IPSA and study abroad host procedures and
regulations. This Agreement will be effective when my application is
accepted by IPSA and shall be governed by the laws of the State of Arizona.
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 the completed and signed application
for your records and enclose your payment.
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