IPSA - International Partners for Study Abroad 



to English Language School in Miami

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 13832 N 32nd Street, Suite 151 Phoenix, AZ 85032, USA or by Fax to: +1 (602) 942-6734 Application Deadlines 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): ___________________ SSN (U.S. citizens): _____-___-_______ 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: ______________________________________ ___________________________________________________________________________


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. 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, on which Visa do you intend to enter the United States? ____________________________________________________________________________

Part B. Program data:

I Wish to Start Classes on ____(Day) _______________(Month) ________(Year) I want to register for the following program: __General English ESL Program (__full-time __part-time) __One-to-one private classes. Please enter the number of lessons a day: _____ and other comments: __________________________________________________________________________ __________________________________________________________________________ Please enter a number of weeks you want to study: ______ weeks 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 require help with accommodations? __ Yes __No If yes, what type of accomodation would you prefer? __Host Family: __ single room __double room __Four Ambassador Suite Hotel: __ single room __double room If you require accommodations other than Host Family, please enter your requirements: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 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. 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$80 and a course registration fee of $100 and a Tuition Deposit of $200 are required with the application. If you have requested accommodations, please also send a non-refundable accommodation placement fee of $150. 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 13832 N 32nd Street, Suite 151 Phoenix, AZ 85032, 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 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: ___________________ 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.