IPSA - International Partners for Study Abroad
Application
to English Language School in Jeffreys Bay, South Africa
Please print out this form from your browser,
complete (print or type) and sign the Apllication
and send it by mail to:
IPSA
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: __________________
Do you need a student visa to study in Spain? __yes __no
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:
Which program do you want to attend?
__I want to attend General English Course
__I want to attend General English Focus Course
__I want to attend Business English Course
__I want to attend Examination Preparation Course
__I want to attend ____ Private English (One-To-One) classes a week
(15 classes per week minimum)
I Wish to Start Classes on ___(Day) _____________ (Mo) ______(Year)
For how many weeks do you want to register: ____Number of weeks
I will arrive on ________________________________ (Day-Month-Year)
What is your present level of English?
Speaking / Listening: __Beginner __Intermediate __Advanced
Reading / Writing: __Beginner __Intermediate __Advanced
Have you taken one of these English Tests?
TOEFL. Date:______________________________ Score: ________________________
TWE. Date:______________________________ Score: ________________________
IELTS. Date:______________________________ Total Score: __________________
Reading: ______ Writing: _________ Listening: _______ Speaking: _________
Accomodations:
Do you want us to arrange accommodation for you? __yes __no
If yes, what form of accommodation?
__Homestay, Basic room
__Homestay, En-suite room
__School Residence, Single Room/ Double Room
__School Residence, Double Room
__School Residence, Sharing Double
__School Residence, Dormitory
__Beach Front School Residence
__Hotel
__Other. Please specify: _________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Do you smoke? __yes __no
Will you live in a house with children? __yes __no
Will you live in a house with pets? __yes __no
Are there any foods you cannot eat? __yes __no
If yes, please provide details: ___________________________________________
___________________________________________________________________________
Do you want us to meet you at the Airport when you arrive? __yes __no
Number of people arriving: ___________
Airline and flight number (if known*): ____________________________________
Arrival date (if known*): _________________________________________________
Arrival time (if known*): _________________________________________________
* Please inform us about your flight details no later than 10 days before
the arrival.
Part C. Payment of Fees:
A non-refundable application fee of US$100 and a tuition deposit of US$200
are required with your application. If you apply l ess than 30 days before
the program starts, please also send a last minute booking supplement of
US$60.00. The above fees and deposit are part of the cost of your program
and are deducted from the total of the program fees after conversion them in
Euro according to the current local exchange rate. Please note that your
application will be considered only when your payment of the application
fee and the tuition deposit has been received.
Please also note that we must receive the full payment of tuition and
accommodation fees due at least 30 days before the commencement of your
program.
All payments of application fees and deposit must be made in U.S.Dollars
and payable through U.S. banks. Any collection charges will be applicant's
responsibility. Checks or international money orders drawn on foreign banks
will not be accepted.
IPSA
40240 N. 69th Place
Cave Creek, AZ 85331, USA
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 this completed and signed application
for your records and enclose your payment of the application fee.
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