IPSA - International Partners for Study Abroad 

                       

Application

to Italian Language School in Florence, Italy

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 and a full payment no later than 40 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:

I Wish to Start Classes on ____(Day) _______________(Month) ________(Year) I Wish to Book: ____ Weeks Which course would you like to study? __Group Italian Language Course (20 lessons per week) __Group Combined Course (4 hours in group + 2 hours of Individual lessons) __Individual (One-to-One) Italian Language Course Please check a number of individual lessons per day: __2 __3 __4 __6 __8 __Individual Tutor Course at the Teacher's Home __C.I.L.S. Preparation Course __Teacher Training Course I have studied Italian for __Years at a ___________________________________ (type of school e.g. high school, university, private language school) What is your present level of Italian? __Beginner __Elementary __Low Intermediate __Intermediate __Advanced

Accomodations:

Do you need accommodation? __ Yes __No If yes, what type of accomodation would you prefer? First Choice Second Choice Single Room with family or single person without kitchen ___ ___ Double Room with family or single person without kitchen ___ ___ Single Room in student apartment with kitchen ___ ___ Double Room in student apartment with kitchen ___ ___ Single Room with family with breakfast ___ ___ Double Room with family with breakfast ___ ___ Single Room with family with halfboard ___ ___ Double Room with family with halfboard ___ ___ Hotel Albergo Firenze Single room ___ ___ Hotel Albergo Firenze Double room ___ ___ Hotel Albergo Adam Single room ___ ___ Hotel Albergo Adam Double room ___ ___ Hotel Albergo Cavour Single room ___ ___ Hotel Albergo Cavour Double room ___ ___ Please check two choices. Accommodation Reservation is subject to space availability. Do you smoke? __Yes __No Do you have allergies to food/animals? List: _______________________________ ____________________________________________________________________________ Accommodation will be arranged subject to availability. 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 a non-refundable Application Fee of US$80 and tuition deposit of US$200 has been received. The tuition deposit is a part of the cost of your course and is deducted from the total tuition fees after conversion in Euro according to the current exchange rate. The full payment of the program fees is due no later than 40 days before the program starts. Payments of the application fee and deposit 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 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 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 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.