IPSA - International Partners for Study Abroad

             

Application to IPSA Language Institute in West Palm Beach

Please print out this form from your browser, complete (print or type) and sign the Apllication and send it by mail to: West Palm Beach Language Institute 224 Datura Street, Suite 1100 West Palm Beach, FL 33401, USA or by Fax to: +1 (561) 629-5983

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: __________________ Passport number: ______________________ 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: ______________________________________ ___________________________________________________________________________

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 an F1 student currently in the United States, you can transfer to our school. After we receive your application,we will send you the Transfer Form upon your registation. You will need to bring this form to your current school's student advisor and ask them to return the form to us by fax. 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 - your country and city).

Emergency Contact:

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

Part B. Program data:

I Wish to Start Classes on ____(Day) _______________(Month) ________(Year) I Wish to Book: ____ Weeks Which course would you like to study? Intensive English ESL Courses (Downtown Campus): __Intensive English course (20 group lessons a week) Schedule: __AM __PM __Intensive Plus English course (28 group lessons a week) Intensive English Program for International F-1 Students (Forest Hill Blvd. Campus): __Intensive English Program for International F-1 Students (8 weeks min) General English ESL Courses (Downtown Campus): __Afternoon Course (4 group lessons a week) __Evening Course (4 group lessons a week) __Saturday Course (4 group lessons a week) Private General English Classes (Downtown Campus) __Private General English ESL Course with ___ one-to-one lessons per week (10 lessons minimum) Private General English ESL Classes Comments: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ American English Pronunciation & Accent Reduction (Downtown Campus) __American English Pronunciation & Accent Reduction 6-week program with 4 group lessons a week __I want to book American English Pronunciation & Accent Reduction program with the total number of ____ one-to-one lessons (10 lessons minimum) English for Specific Purposes Courses (Downtown Campus) __American Idioms and Vocabulary Building __English for Telephoning __English in the Workplace __English for Job Search Success __Practical English Writing Skills Workshop English for Specific Purposes courses are offered in mini-group classes for our students enrolled in the Intensive General English Plus program and as one-on-one lessons with flexible schedules. Please select one of the following: __I applied for the Intensive Plus program and want to attend the selected English for Specific Purposes course(s) in mini-group __I want to book the selected English for Specific Purposes course(s) with the total number of ___ one-to-one lessons (10 lessons minimum) Comments: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Test Preparation Courses (Downtown Campus) __TOEFL __TOEIC __IELTS Test Preparation Courses are offered as group classes with 4 lessons per week for 6 weeks and as one-on-one lessons with flexible schedules. Please select one of the following: __I want to attend the selected Test Preparation course for 6 weeks in group __I want to book the selected Test Preparation course with the total number of ____ one-to-one lessons (10 lessons minimum) Comments: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ English Courses for Executives and Professionals (Downtown Campus) Mini-Group Courses for Executives and Professionals: __Mini-Group Course for Executives and Professionals with 20 lessons a week __I also want to book additional 10 one-to-one lessons per week Private One-to-One Courses for Executives and Professionals: __Private Executive English Course with 15 one-to-one lessons per week __Private Executive English Course with 20 one-to-one lessons per week __Private Executive English Course with 25 one-to-one lessons per week __Private Executive English Course with 30 one-to-one lessons per week __ Private Executive English Course with 35 one-to-one lessons per week All English courses for Executives and Professionals are tailor-made and include development of your general English language skills, remedial work on pronunciation and accent reduction and vocabulary building and writing skills, specific to your profession, as well as English for Specific purposes: telephone skills, meetings, presentations, etc. Upon registration we will send you the Executive Course Needs Analysis that will help us assess your requirements and formulate a unique program tailored to your needs. Please select your program specialization: __ General Executive English tailored to my specific learning needs __ Business English for Executives __ English for Accounting & Finance __ English for Customer Care __ English for Human Resources __ English for Logistics __ English for Marketing & Advertising __ English for Sales & Purchasing __ English for Aviation __ English for Law Enforcement __ English for Military Please enter any comments below regarding your learning goals. ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ I also want to book English Classes Outside Classroom (min. 10 hours a week) This program can be booked only in addition to any of our group and/or private courses. Please enter the number of hours per week : _____ 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? __Absolute Beginner __ Beginner with some knowledge __Elementary __Low Intermediate __Intermediate __Advanced What are your language learning goals: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

Accomodations:

please select one of the following options: __ Hotel __ Condo/Apartment __ Private House __Host family Please also answer the questions below: Do you smoke? __Yes __No Smoking is allowed only outside the residence. Do you have allergies? List: _______________________________________ ____________________________________________________________________________ Other requirements: ____________________________________________________________________________ ____________________________________________________________________________ Accommodation will be arranged subject to availability. 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:

A non-refundable application fee of US$100.00 (intensive and executive courses) or $50.00 (afternoon, evening and Saturday General English, Test preparation and Accent Reductions courses), course registration fee of $150.00 (F-1 Students only) and a tuition deposit of $200.00 are required with your application. The Tuition Deposit is part of the cost of your course and is deducted from the total tuition fees. The tuition deposit is not an additional cost. Please note that your application is considered only when your payment of the enrollment fees and the tuition deposit has been received. If you require our help with finding accommodations for you, please also pay the accommodation finding fee of $150.00 with your application. Upon receiving your application, application fee and deposit, we will send you a registration confirmation and invoice. You may pay the balance by wire transfer, check/money order, or by credit card. Please select one of the following payment options: 1. __Please find enclosed a certified check/money order for the registration fee and the program 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: West Palm Beach Language Institute 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 registration 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: ___ registration fee and deposit __ registration fee and the full payment Even if you select a "full payment" option, we will charge the registration fee and the program 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% convenience payment processing service fee will be included in the invoice. There are no any additional charges on your payment of the registration fee and the program deposit by credit card. 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 West Palm Beach Language Institute and IPSA website constitute part of my agreement with IPSA, agents, representatives 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 West Palm Beach Language Institute and all their officers, agents and employees from and against any and all claims of damage to personal property and/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 terms and conditions of enrollment and agree to follow all West Palm Beach Language Institute and IPSA procedures. This Agreement will be effective when my application is accepted by IPSA and shall be governed by the laws of the State of Florida, USA. Applicant's Signature ______________________ 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.