IPSA - International Partners for Study Abroad 

                       

Application

to Language School in Montevideo, Uruguay

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) Major field of study: _____________________________________________________ Address of your school, college, university, or company: ___________________________________________________________________________

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: __ Spanish Intensive Course, 20 lessons a week (course A) __ Spanish Super Intensive Course, 30 lessons a week (course B) __Private Spanish Course __ private lessons per week (course c) __Business Spanish (course D) __Spanish for Children (course E) __Spanish for Seniors (course F) __Internship Program __Volunteer Program __Spanish + Tennis (course G) __Spanish + Sailing (course H) __Spanish + Windsurfing (course I) __Spanish + Tango (course J) __Spanish + Diving (course K) __Spanish + Horse Riding (course L) 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 Spanish? __Beginner __Intermediate __Advanced __Superior

Accomodations:

Do you need accommodation? __ Yes __No If yes, what type of accomodation would you prefer? __Homestay with single room __Student Residence, single room/shared bath __Student Residence, double room/shared bath __Student Residence, Single room with private bathroom __Student Residence, Double room with private bathroom __Apartment Accommodation will be arranged subject to availability.

Airport pickup:

Do you need airport pickup? __ Yes __No If yes, what type of accomodation would you prefer? Arrival Date: __ (Day) _______ (Month) ____ (Year) Arrival Time: _______ (24 hour clock) Arrival Location: _________ (airport) Airline and flight number: ____________ Departure city: _______________________________

Part C. Payment of Fees:

Please note that your application will be considered only when your payment of the non-refundable application fee of US $80.00, and tuition deposit of $200 has been received. The Program 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.