IPSA - International Partners for Study Abroad 



to English Language School in Denver

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 224 Datura Street, Suite 1100 West Palm Beach, FL 33401, USA or by Fax to: +1 (561) 629-5983 Application Deadlines Normally, we must receive a complete set of application documents and fees no later than 30 days (21 days - if you do not need I-20) 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: ______________________________________ ___________________________________________________________________________


It is advisable that students have health insurance while residing or traveling in the United States. The insurance carrier in the student's home country can provide this coverage, or short term health coverage through an American company can be arranged. The School now requires all students to have health insurance. You must show proof of this before starting classes, or we can offer this service for $78/month. My insurance company is: _________________________________________________ Policy Number: ____________________________________________________________

Emergency Contact:

Name: ________________________________________________________________ Relationship:______________________ Telephone: ________________________ Address: _____________________________________________________________

Status and Visa Information:

Are you NOW in the United States? __Yes __No a. If your answer is yes, when did you come to the United States? Month:___________________ Year: _______ b. What type of visa do you hold? ________________________________________ If you are not in the United States at this moment, do you wish to be sent an I-20 for a student Visa? __Yes __No If no, on which Visa do you intend to enter the United States? _________ Do you request Express courier service to send you an I-20 for a student Visa? __Yes __No

Part B. Program data:

I Wish to Start Classes on ____(Day) _______________(Month) ________(Year) (You can start classes on any Monday.) How Many weeks do you plan to attend? Please enter a number of weeks______ I want to register for the following program: (Please check a program below)

Exectutive Programs:

__ Platinum Executive 1 Plus - Immersion plus "Live and Learn" __ Platinum Executive 1 - Immersion __ Gold Executive 2 - Group instruction + Private instruction __ Silver Executive 3 - Group instruction (minimum enrolment: 4 weeks) __ Executive Private Classes with ___ lessons per week (12 lessons a week minimum) __I am interested in Family Package: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

Intensive English Programs for Students

__Platinum Intensive English (minimum enrollment: 1 week) __Gold Intensive English (minimum enrollment: 2 weeks) __Silver Intensive English (minimum enrollment: 4 weeks) __Academic English Program (minimum enrolment: 1 term) __Student Private Classes with ___ lessons per week (12 lessons a week minimum) __University Placement Service - Undergraduate __University Placement Service - Graduate

Junior Winter Program

__Junior Winter program __ add Ski/Snowboard Intensive Package

Test Preparation

__Intensive GRE Preparation (12 weeks) __One-on-one GRE Preparation classes (12 hours package) __One-on-one GRE Preparation classes (36 hours package) __IELTS Preparation (4 weeks) __One-on-one IELTS Preparation classes (12 hours package) __One-on-one IELTS Preparation classes (36 hours package) Are you interested in TOEFL/TOEIC preparation courses? __TOEFL __TOEIC

Elective Course Options

Please check the course options which are of most interest to you: English for Business: English & American Studies: __Business Correspondence __Reading for Comprehension and Vocabulary __Telephoning in English __Writing Workshop __Business Grammar __American Film Series: American Idioms, Listening and Vocabulary __Management __Current Events and News Stories: Discussion & Debate __Business Vocabulary __News for Now __Making Presentations __English Grammar __Negotiating Skills __University Preparation __Marketing __Presentations and Public Speaking __Business Law __Conversational English for Everyday Purposes __Introduction to Information Technology I have studied English for __years at a ____________________________________ ____________________________________________________________________________ (type of school e.g. high school, university, private language school) What is your present level of English? __Beginner __Elementary __Low Intermediate __Intermediate __Advanced


Do you need accommodation? __ Yes __No If yes, what type of accomodation would you prefer? __Apart-Hotel (Homestead Village) __Hotel (Four Points Sheraton) __Host Family 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. Students opting for Host Family lodging will be picked up and delivered to the airport by their host family provided they arrive or depart on a weekend. Weekday pickup/delivery will be charged the airport pickup fee. Car Rental The School offers a limited number of cars for rental to executive students. Please indicate if you would like to rent a car: __Yes. __No. From: Day:___ Month:______________________________ Year:_______________ To: Day:___ Month:______________________________ Year:_______________

Part C. Payment of Fees:

Please note that your application will be considered only when your payment of the non-refundable application fee of $155 and a tuition deposit of $350 has been received. The Tuition Deposit is part of the cost of your course and is deducted from the total tuition fees. 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 224 Datura Street, Suite 1100 West Palm Beach, FL 33401, 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 "full payment" option), a 4.5% convenience payment processing service fee will be included in the invoice. There is no any additional charge when you pay the application fee and the tuition deposit by credit card. 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.