IPSA - International Partners for Study Abroad 



to English Language School in Hawaii

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 your 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: ______________________________________ ___________________________________________________________________________


Medical bills in the United States are expensive. It is recommended that you have medical insurance to cover you against accident or sickness while in the United States. The School now requires all students to have health insurance. You must show proof of this before starting classes. 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 If yes, an additional fee will apply.

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) __ Intensive English Program (IEP) - Kalakaua Campus __ Super Intensive English Program (IEP) - Kalakaua Campus __ Academic Track Program (4 months) - Kalakaua Campus __ TOEFL STEP - Kalakaua Campus, 20 lessons per week __ TOEFL Intensive - Kalakaua Campus, 25 lessons per week __ Intensive English Program for Executives, 35 lessons per week - Kalakaua Campus __ Certificate in Business English Program, 10 lessons per week - Kalakaua Campus __ Short Term English Program (STEP) - Kalakaua Campus __ Short Term English Program (STEP) - Kalakaua Campus __ Conversation Cafe - Kalakaua Campus __ Conversation Cafe for 50+ - Kalakaua Campus __ Summer ESL Program for Kids (K-STEP) - Kalakaua Campus __ Summer ESL Program for Teens (J-STEP) - Kalakaua Campus __ Winter ESL Program for Teens (J-STEP) - Kalakaua Campus __ Private Tuition with ____ Lessons per week: Private Tuition Specialization (General English, Business English, TOEFL/ TOEIC preparation, Pronunciation, Writing, etc.): ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 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 Note: Short-term (less than 6 months) accommodation prices in Honolulu vary greatly due to the type of accommodation (hotel, condo, hostel, apartment, etc.), seasonal factors (Winter is high season), location and condition of the building (near beach?, new building?, swimming pool?), size of rooms (studio?, 1-bdrm?), and furnishings provided (kitchen?, kitchenette?, TV?, study desk?) What type of accomodation would you prefer? __Hotel __Hostel __Condominium __Host Family Please enter below your accommodation requirements including price range and /or preferences: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 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: _______________________________ 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 non-refundable application fee of $100, registration fee of $150 and the Tuition Deposit of $250 has been received. If you apply for K-STEP or J-STEP summer program, your payment of activity fee ($250 per week) is also required with your application. 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: ___ enrollment fees 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 this completed and signed application for your records and enclose your payment of the application fee and deposits.