Application to English Language School in Hawaii, USA.


               IPSA - International Partners for Study Abroad

Application

to English Language School in Hawaii


                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 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 
following information: 

Current college/university/graduate school:  ______________________________

___________________________________________________________________________

Major field of study: _____________________________________________________

Address of your college, university: ______________________________________

___________________________________________________________________________

Insurance:


Medical bills in the United States are expensive. It is recommended that you 
have medical insurance to cover you against accident or sickness while in the 
United States. The School now requires all students to have health insurance. 
You must show proof of this before starting classes. 

My insurance company is:  _________________________________________________ 
 
Policy Number: ____________________________________________________________

Emergency Contact:


   Name:   ________________________________________________________________

   Relationship:______________________  Telephone: ________________________
 
   Address:   _____________________________________________________________

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, an additional fee will apply.

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) 

__ Intensive English Program (IEP) - Kalakaua Campus 

__ Super Intensive English Program (IEP) - Kalakaua Campus 
 
__ Academic Track Program (4 months) - Kalakaua Campus 

__ TOEFL STEP - Kalakaua Campus, 16 hours per week

__ TOEFL Intensive - Kalakaua Campus, 20 hours per week

__ Intensive English Program for Executives, 28 hour per week - Kalakaua Campus 

__ Certificate in Business English Program, 8 hours per week - Kalakaua Campus 

__ Short Term English Program (STEP) - Kalakaua Campus 

__ Short Term English Program (STEP) - Kalakaua Campus 

__ Conversation Cafe - Kalakaua Campus 

__ Conversation Cafe for 50+ - Kalakaua Campus 

__ ESL Program for Kids (K-STEP) - Kalakaua Campus 

__ English Discovery Camp (4-6 Years) - Kalakaua Campus 

__YMCA English Summer Camp (8-15 years) - Kalakaua Campus

__ ESL Program for Teens (J-STEP) - Kalakaua Campus



__General English, 25 lessons a week (Ala Moana Campus) 

__ General English, 20 lessons a week (Ala Moana Campus) 

__ General English, 16 lessons a week (Ala Moana Campus) 

__ TOEFL preparation, 25 lessons a week (Ala Moana Campus) 

__ TOEFL preparation, 20 lessons a week (Ala Moana Campus) 

__ TOEIC preparation, 25 lessons a week (Ala Moana Campus) 

__ TOEIC preparation, 20 lessons a week (Ala Moana Campus) 

__ Academic Year Program, 36 weeks, 25 lessons a week (Ala Moana Campus) 

__ Academic Year Program, 36 weeks, 20 lessons a week (Ala Moana Campus) 

__ Semester Program, 23 weeks, 25 lessons a week (Ala Moana Campus) 

__ Semester Program, 23 weeks, 20 lessons a week (Ala Moana Campus) 

__ Cambridge Exam Preparation (FCE and CAE), 9 weeks, 30 lessons a week 

__ CAE Support Package (Ala Moana Campus) 

__ Cambridge Exam Preparation (FCE and CAE), 12 weeks, 20 lessons a week

__ Teen Activity Program (Ala Moana Campus) 

__ English plus Surfing (Ala Moana Campus) 

__ Private Tuition with ____ Lessons per week:

   Private Tuition Specialization (General English, Business English, TOEFL/
   TOEIC preparation, Pronunciation, Writing, etc.):

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________


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

Accomodations:


Do you need accommodation? __ Yes   __No 

Note: Short-term (less than 6 months)  accommodation prices in Honolulu vary 
greatly due to the type of  accommodation  (hotel, condo, hostel, apartment, 
etc.), seasonal factors (Winter is  high  season), location and condition of 
the building  (near beach?,  new building?,  swimming pool?),  size of rooms 
(studio?, 1-bdrm?), and furnishings provided (kitchen?,  kitchenette?,  TV?, 
study desk?) 

What type of accomodation would you prefer? 

__Hotel   __Hostel   __Condominium   __Host Family 

Please enter below your accommodation requirements including price range and
/or preferences: 

____________________________________________________________________________

____________________________________________________________________________ 

____________________________________________________________________________

____________________________________________________________________________ 


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: _______________________________


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 $100, registration fee of $125 and 
the Tuition Deposit of $250 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:

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 Study Abroad International 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 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  all  terms and conditiones and 
rules and  agree  to  follow  all  IPSA and study abroad host procedures and 
regulations.  This  Agreement  will  be  effective  when  my  application is 
accepted by IPSA and shall be governed by the laws of the State of Arizona.



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.