IPSA - International Partners for Study Abroad 

                       

Application

to Spanish Language School in Manta, Ecuador.

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 21 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: ______________________________________ ___________________________________________________________________________

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? __Individual Intensive Spanish Language Course Please check a number of hours of instruction per week: __20 lessons/week __25 lessons/week __30 lessons/week __35 lessons/week __Medical Spanish Program __Manta Activo: Please check a number of hours of instruction per day: __6 lessons per day __7 lessons per day __Eco Volunteer Program __6 weeks __8 weeks __Spanish & Surfing __Spanish + Kiteboarding __Closed Group Spanish Language Course Please enter the number of students in your group arriving together (including yourself) ____ Please check a number of hours of instruction per week: __15 lessons/week __20 lessons/week __25 lessons/week List the name and age of each person arriving with you: 1. ________________________________________________________________________ 2. ________________________________________________________________________ 3. ________________________________________________________________________ 4. ________________________________________________________________________ By submitting this application, you confirm that you are applying for the group course on behalf of yourself & each person listed above and agree to pay application fees and deposits for each person. Otherwise, please ask you friends to submit their own applications. What is your present level of Spanish? __Beginner __Elementary __Low Intermediate __Intermediate __Advanced Comments: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

Part C. Accomodations.

Do you require help with accommodations? __yes __no If yes, please select the accommodations you prefer: __Homestay __Students' Apartment Other accommodation requirements: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ If you require host family 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 $100.00 and the tuition deposit of $200 has been received. 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 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.