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 Application Deadlines 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 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 Brazil. The insurance carrier in the student's home country can provide this coverage. My insurance company is: _________________________________________________ Policy Number: ____________________________________________________________

Emergency Contact:

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

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) __Volunteer Program __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 __Other: _________________________________________________________________ ____________________________________________________________________________


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: 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 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 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.