IPSA - International Partners for Study Abroad
to English Language School in Boston
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 a complete set of application documents
and 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 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 the United States. The insurance carrier in the student's home
country can provide this coverage, or short term health coverage through an
American company can be arranged. The School now requires all students to
have health insurance. You must show proof of this before starting classes,
or we can offer this service for $65/month.
My insurance company is: _________________________________________________
Policy Number: ____________________________________________________________
Relationship:______________________ Telephone: ________________________
Status and Visa Information:
Are you NOW in the United States? __Yes __No
a. If your answer is yes, when did you come to the United States?
Month:___________________ Year: _______
b. What type of visa do you hold? ________________________________________
If you are not in the United States at this moment, do you wish to be sent
an I-20 for a student Visa? __Yes __No
If no, on which Visa do you intend to enter the United States? _________
Do you request Express courier service to send you an I-20 for a student
Visa? __Yes __No
If yes, please note that an additional fee is required with your application
(the amount of the fee varies depending on destination).
Part B. Program data:
I Wish to Start Classes on ____(Day) _______________(Month) ________(Year)
How Many weeks do you plan to attend? Please enter a number of weeks______
Intensive, Intensive Plus, Semi-Intensive and Combination Courses are reserved
in sessions of 4 weeks. Therefore you can reserve a place for 4/8/12/16/20 ...
weeks if you want to register for the above courses. You may register for
Individualized one-on-one program for 1, 2, 3, 4 and more weeks and start any
I want to register for the following program: (Please check a program below)
__Intensive English ESL course (25 lessons per week)
__Intensive Plus ESL course (30 lessons per week)
__Standard ESL course (20 lessons per week)
__TOEFL Preparation course (24 lessons per week)
__Combination Group class and individual one-on-one tutoring
__Group Business English Program
__Business Group plus Private
__Business English - One-to-one, 20 lessons per week
__Business English - One-to-one, 30 lessons per week
__Evening ESL Program
__Saturday ESL Program
__Individualized one-on-one program - 20 lessons per week
__Individualized one-on-one program - 30 lessons per week
__Private course with less than 20 lessons per week
I want to register for the total number of ___ hours of private instruction
I have studied English for __years at a ____________________________________
(type of school e.g. high school, university, private language school)
What is your present level of English?
__Beginner __Elementary __Low Intermediate __Intermediate __Advanced
Do you need accommodation? __ Yes __No
If yes, what type of accomodation would you prefer?
__Host Family - Single Room with breakfast and dinner
__Host Family - Double Room with breakfast and dinner
__Host Family - Single Room (meals not included)
__Student Residence Hall (Dormitory)
__Apartment - Studio __Apartment - One bedroom __Apartment - Two bedroom
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 enrollment fes and deposits has been received.
A non-refundable application fee of US$100 and a course registration fee ($140
- for international students or $50 - for domestic students), and a Tuition
Deposit of $300 are required with the application (domestic students applying
for part-time courses do not need to pay the tuition deposit).
If you have requested accommodations, please also send a non-refundable
accommodation placement fee of $100 and a housing security deposit of $200.
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.
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: ___________________
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.