IPSA - International Partners for Study Abroad
to Portuguese Language School in Sao Paulo
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
Normally, we must receive a complete set of application documents
and fees no later than 30 days before the program starts.
Acceptance of late applications is subject to space availability.
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
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 Brazil. The insurance carrier in the student's home
country can provide this coverage.
My insurance company is: _________________________________________________
Policy Number: ____________________________________________________________
Relationship:______________________ Telephone: ________________________
Part B. Program data:
I Wish to Start Classes on ____(Day) _______________(Month) ________(Year)
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)
__Group Intensive Program (20 hours per week, 2 weeks minimum)
__Group Super Intensive Program (30 hours per week)
__Private Intensive Program (20 hours per week)
__Private Executive Program (30 hours per week)
__Private VIP Super Intensive Immersion Program (50 hours per week)
__Salud Medical Brazil Program
Have you studied Portuguese 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 Portuguese?
__Beginner __Elementary __Intermediate __Upper-intermediate __Advanced
Which areas would you most like to improve:
__Speaking __Understanding __Listening __Reading __Writing __Vocabulary
Do you need accommodation? __ Yes __No
If yes, what type of accomodation would you prefer?
__Family House __Hotel __Apartment
Accommodations in a family house is included in the all-inclusive Program Fee. Options
for hotels, pousadas(guest house) and apartments are available on request.
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 non-refundable appplication fee of $155 USD and the tuition
deposit of $200 USD has been received.
Upon registering you for the course, we will send you an invoice for the balance
due and different payment options and instructions (you will be able to pay the
balance by check/money order, wire transfer or by credit card).
All payments must be made in U.S. Dollars and payable through the US banks. Any
payment processing charges will be the applicant's responsibility.
Checks or international money orders drawn on foreign banks will not be accepted.
You can also select one of the following payment options to pay
the registration fee:
1. __Please find enclosed a certified check/money order for the application fee.
Cashiers Checks or international money orders must be made payable to IPSA.
Please send a check or international money order with your application to:
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 by wire transfer. Please send me the
instructions on how to send the wire transfer to your 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 only ___ application fee and full payment due
Even if you select a "full payment" option, we will charge only registration
fee 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.
__ Please find enclosed a copy of the wire transfer/bank draft
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: ___________________
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.