IPSA - International Partners for Study Abroad 



to English/French Language School in Ottawa, Canada.

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 5 weeks 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: ______________________________________ ___________________________________________________________________________

Emergency Contact:

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

Part B. Program data:

For how many weeks you want to register: Number of weeks: ______ I Wish to Start Classes on ___(Day) _____________ (Mo) ______(Year) Which course would you like to study?

English for Adult Learners

__Intensive English Course: (31 lessons a week) __Full-time English Course: (24 lessons a week) __Part Time English Course (12 lessons per week) __ TOEFL preparation

English Summer Junior Programs:

__Junior English Summer Immersion Program for Adolescents __English Day Camp __English Camp with Homestay __English Camp with Residence __ Parent & Child Combo (English or French) Optional Saturday trips: __Yes __No What is your present level of English? __Beginner __Elementary __Low Intermediate __Intermediate __Advanced

Part C. Accomodations.

Do you require help with accommodations? __yes __no If yes, please select the accommodations you prefer: __Homestay: __Full Board (2 meals per day) __ Breakfast only __Residence Accommodation If you require accommodations, please also fill in below: Are you a smoker? __yes __no If you have a special diet, please specify: ___________________________________________________________________________ If you have allergies, please specify: ___________________________________________________________________________ If you have other requirements, please specify ___________________________________________________________________________ ___________________________________________________________________________

Part D. Payment of Fees:

Please note that your application will be considered only when your payment of the non-refundable Application Fee of US$100 and Tuition Deposit of US$200 ($400 - if you apply for the Junior summer program for kids and teens or Parent and child combo) has been received. Upon receiving your application and your payment of the required fee(s) and the tuition deposit, we will send you a registration confirmation and invoice for the balance in Canadian Dollars converted in U.S. Dollars or in Euro according to the current exchange rate for buyers communicated by IPSA on the invoice date. The balance must be paid in U.S. Dollars or in Euro. Please note that a full payment of the balance is due upon the receipt of invoice. Your place will be confirmed only when the full payment has been received. 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 4.5% convenient payment processing service fee will be included in the invoice. There are no any additional charges if you pay the application fee and the tuition deposit by credit card. Comments: _________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

Part E. 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.