IPSA - International Partners for Study Abroad 

                       

Application

to Language School in Lausanne, Switzerland

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 tuition fees no later than 30 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 __ High (Secondary) School Student University student: __ freshman __ sophomore __ junior __ senior __ Graduate Student __ Professional Please enter your profession: _________________________________________ If you are a high (secondary) school student, please provide the following information: Name(s) and year(s) of last schools attended (and certificate(s) if any: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ (Please enclose a School certificate for last year) 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 school, college, university, or company: ___________________________________________________________________________

Insurance:

The Swiss law (1st January 1996) concerning sickness and accident insurance demands that all students, residing in Switzerland, be insured against sickness and accidents by a recognized Insurance Company. The School provides accident insurance for all students, but you also need a health insurance. We would therefore be grateful if, upon your arrival at the School, you could provide us with a statement from your Insurance Company, certifying that you are also covered in Switzerland. (Hospital - Doctor - Pharmacy) If this is not the case, we have to insure you at the School for the period of your stay. Please check on of the following: __My insurance against illness is valid in Switzerland __I would like to be insured by the The School

Parents/guardian:
(if applicant is under 18 years old)

Name and address of parents/gardian: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Father: Profession: _______________________________ Tel. (work)_________________ Fax: _________________________________ Tel. (home) _____________________ Mother: Profession: _______________________________ Tel. (work)_________________ Fax: _________________________________ Tel. (home) _____________________ Reports to be sent to: __parents __student __gardian Bills to be sent to: __parents __student __gardian

Emergency Contact:

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

Part B. Program data:

I Wish to Start Classes on ____(Day) _______________(Month) ________(Year) Please check the course you would like to study:

French (French plus English)

__French Intensive Language Program: 25 periods of instruction per week __French Intensive Language Program: 35 periods of instruction per week __French Intensive Language Program (25 periods per week) Plus 10 periods of English per week I Wish to Book: __Academic Year program - 32 weeks OR Number of 10-week Terms: ______ OR Number of weeks, if you want to book less than 10 weeks: ______

English (English plus French)

__English Intensive Language Program: 25 periods of instruction per week __English Intensive Language Program: 35 periods of instruction per week __English Intensive Language Program (25 periods per week) Plus 10 periods of French per week I Wish to Book: __Academic Year program - 32 weeks OR Number of 10-week Terms: ______ OR Number of weeks, if you want to book less than 10 weeks: ______

Summer Course

__15 hours a week (14 year old and over) __20 hours a week (14 year old and over) __20 hours a week IELTS preparation (14 year old and over) I Wish to Book: __ weeks Please select the language for the summer course: __French Summer course __English Summer course Comments: ___________________________________________________________________________ ___________________________________________________________________________ I have studied the language for __Years at a ______________________________ (type of school e.g. high school, university, private language school) What is your present level of the language you want to study? French: __Beginner __Elementary __Low Intermediate __Intermediate __Advanced English: __Beginner __Elementary __Low Intermediate __Intermediate __Advanced

Accomodations:

Do you need accommodation? __ Yes __No If yes, what type of accomodation would you prefer? __Boarding House If you have checked a Boarding School option, please select: __Single Room __Double Room __Standard Room __ Comfort Room __ Comfort Plus Room __One room flat (studio) Comments: ___________________________________________________________________________ ___________________________________________________________________________ Accommodation will be arranged subject to availability.

Activities and Lunches
for Non-Boarding Students:

Do you wish to participate in sporting activities & excursions? __Yes __No Do you wish to have lunches at the School? __Yes __No

Part C. Payment of Fees:

Please note that your application will be considered only when your payment of the non-refundable Application Fee of $150 and the tuition deposit of $250 has been received. The Tuition Deposit is part of the cost of your course and is deducted from the total program fees. 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 and course registration 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: ___ enrollment fees 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 this web site constitute part of my agreement with IPSA and study abroad program host (university, college, language school, or other institution or organization), including sections concerning responsibility, health, refunds, changes in dates, accommodations, courses and billing of the selected options. I have read this Agreement and agree to follow all IPSA and study abroad host procedures. This Agreement will be effective when my application i s 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.