Quebec & Montreal · 2016 Registration Form
Personal Information First Name
Middle Name
Last Name
Address Postal/ZIP code
Country
City
State/Province
Nationality
Date of birth (mm/dd/yyyy)
Phone number
Cellphone Male
Gender
Female
Native Language
English Level
Basic
Intermediate
Advanced
French Level
Basic
Intermediate
Advanced
Emergency Contact Information First Name
Middle Name
Phone number
Last Name
Cellphone
Selected Program City of studies
Montreal
General Programs
Part time
Quebec Full time
Intensive
Super intensive
Both
Course
Bilingual
Lenght
English weeks
French
Start date
Both End date (mm/dd/yyyy)
(mm/dd/yyyy) Private Programs
General
Junior Programs
Summer camp
Business
Hours
Specialty
Winter camp
Other
weeks
Lenght
Kid’s & Parents
Start date
End date (mm/dd/yyyy)
(mm/dd/yyyy) Specialty Programs
Pathway Program
Highschool Experience
Highschool semester
Highschool year
Start date
End date (mm/dd/yyyy)
(mm/dd/yyyy)
Accommodation Type of accommodation
Homestay fullboard
Type of board hs only
Sudent’s house halfboard
Student Residence
Furnished appartment weeks
Lenght
no meals
Other End date
Start date
(mm/dd/yyyy)
(mm/dd/yyyy) Can you live with....
Children?
Cats?
Do you have any allergies?
Yes
No
Specify:
Do you have any illneses?
Yes
No
Specify:
Do you need airport pick-up ?
Yes
Do you smoke?
Dogs?
No
Yes
No
*Please note that most places do not allow smoking indoors.
Medication:
Do you need airport drop-off ?
Yes
No
Arrival date
Arrival time
Flight
(mm/dd/yyyy) Do you need medical insurance ?
Yes
No
All students MUST have medical coverage for their full study period
End date
Start date (mm/dd/yyyy)
Comments
I have read and understood the general payment, cancellation and fefund policies and any other information contained in this document and I agree with its Signature
Date
(mm/dd/yyyy)