IPSA - International Partners for Study Abroad 



to English Language School in Provo

Please print out this form from your browser, complete (print or type) and sign the Apllication and send it by mail to: IPSA 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 40 days (21 days - if you do not need I-20) 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: __________________________________________________ Occupation: _______________________________________________________________ ___________________________________________________________________________

Health Information:

Do you have any special medical restrictions or conditions such as allergies or dietary restrictions and/or physical handicaps that we should be aware of and consider? __NO __YES If Yes, please specify:____________________________________________________ ___________________________________________________________________________ Health Declaration: I am aware that I must arrange for medical insurance for the total duration of my stay in the USA. In the event of a medical emergency during my stay in the USA, I authorize any licensed hospital or physician to initiate treatment, and to release medical information for diagnostic and insurance purposes for follow-up treatment in my home country at my cost. I absolve IPSA and the school and their representatives from any liability for such measures taken on my behalf. I am also aware that these declarations, required by the American government authorities, are legally binding when IPSA and the school accepts my application. Health Insurance can be purchased either before leaving for or after arriving at the school.

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? _________

Part B. Program data:

I Wish to Start Classes on ____(Day) _______________(Month) ________(Year) I want to register for the following program: __Long-Term Semester Program (14 - 16 weeks) for one semester __Long-Term Acaemic Program for ___semesters __Short-term Program for ____weeks __Executive English Program for ____weeks __English Adventure Program for ____weeks Please note that you can apply for this program ONLY if you are arriving with other students in your group of 5 or more students) __Tutor One-to-one course In addition to the above selected Semester or Short Term program, I want to take __one-to-one lessons per day 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? __Homestay __Apartment Rental for Single person __Apartment Rental for Family __Home Rental __Hotel 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:

A non-refundable application fee of US$150.00, course registration fee of $100.00 and a tuition deposit of $250.00 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. If you require accommodation, please also pay the homesaty placement fee of $155.00 with your application. Please note that your application will be considered only when your payment of the enrollment fees and the tuition deposit 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 13832 N 32nd Street, Suite 151 Cave Creek, AZ 85331, 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 ___ enrollment fees 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. There are no any additional charges on your payment of the enrollment fees and the tuition 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 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 the selected options. 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.