IPSA - International Partners for Study Abroad
to Spanish Language School in Lima, Peru.
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 your application no later than 30 days
before the program starts. We accept last minute applications, but
please be aware that acceptance of late applications is subject to
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 Chile. 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)
(You can start classes on any Monday.)
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 Classes with 20 lessons a week
__Private Classes with 20 lessons a week
__I also want to take additional Private Classes.
Number of additional private lessons per week: ____
__Customized Private Spanish Language or Academic Courseh
__Spanish & Surf
__Spanish and Volunter
__Semester Study Abroad Program (16 weeks)
__Academic Year Study Abroad Program (32 weeks)
If you have special concerns, such as health care, business, law, or social
services,etc. or you would like to register for Private classes for less
than 20 hours/week, or Private (additional to the program), or Group program
for less than 20 hours/week, please enter your request below:
Have you studied Spanish 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 Spanish?
__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?
__Shared Apartment (single room)
__Shared Apartment (double room)
Please answer the following questions to help us find a homestay that is
right for you:
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 application fee of $80 and a 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:
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
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. There are no any additional charges on your
payment of the applicatiot fee and the tuition deposit by credit card.
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.