IPSA - International Partners for Study Abroad
Application
to English Language School in San Diego
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 (15 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: __________________________________________________
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:
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. If insurance is needed upon arrival, the
school will provide names of companies that will insure students for 12-180
days.
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
a. If no, on which Visa do you intend to enter the United States? _________
b. Please note that Non-immigrant alien students' documents (I-20) are
provided for students taking a minimum of 20 lessons per week.
Part B. Program data:
I Wish to Book ____ weeks
I Wish to Start Classes on ____(Day) _______________(Month) ________(Year)
Please check the course:
Group courses
__Intensive English __15 lessons/week __20 lessons/week __25 lessons/week
__ESL Literacy __15 lessons/week __20 lessons/week __25 lessons/week
__American Culture __20 lessons/week __25 lessons/week
__English & Volunteering __20 lessons/week __25 lessons/week
__Business English __20 lessons/week __25 lessons/week
__Travel and Hospitality __20 lessons/week __25 lessons/week
Test Preparation courses
__GMAT Preparation __15 lessons/week __20 lessons/week
__MELAB Preparation __15 lessons/week __20 lessons/week
__TOEFL Preparation __15 lessons/week __20 lessons/week
__TOEIC Preparation __15 lessons/week __20 lessons/week
Private English courses
__Private English __private lessons per week (min. 10 per week)
__Legal English __private lessons per week (min. 10 per week)
__Conversation Workshops __private lessons per week (min. 12 per week)
__Accent Reduction __private lessons per week (min. 12 per week)
__Writing Strategies __private lessons per week (min. 12 per week)
__Grammar and Sentence __private lessons per week (min. 12 per week)
__Speech Preparation and Presentation __private lessons per week (min. 12 per week)
__Audio Conferencing - 30 min session __private lessons per week (min. 10 per week)
__Audio Conferencing - 60 min session __private lessons per week (min. 10 per week)
__Video Conferencing - 30 min session __private lessons per week (min. 10 per week)
__Video Conferencing - 60 min session __private lessons per week (min. 10 per week)
English plus Activities courses
__English and Tennis
__English and Golf
__English and Water Polo
__English and Surfing
__English and Sea World
__Parent and Child Combo
Teacher Training Course
__Teacher Training
Silver program for Adults
__Silver program: English for 50+
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
__Upper beginner
__Pre-Intermediate
__Lower Intermediate
__Intermediate
__Upper Intermediate
__Pre-Advanced
__Advanced
Accomodations:
Do you need accommodation? __ Yes __No
If yes, what type of accomodation would you prefer?
__Host Family, single room, half-board
__Host Family, single room, no meals
__Vantaggio Suites Residence Club - Shared Studio
__Vantaggio Suites Residence Club - Private studio (small)
__Vantaggio Suites Residence Club - Private studio (large)
__Studio 819 Residence Club - Private studio (small)
__Studio 819 Residence Club - Private studio (large)
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: _______________________________
____________________________________________________________________________
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:
Please note that your application will be considered only when your payment
of the non-refundable application fee of $150.00, accommodation placement fee
(if required) and the tuition deposit in the amount of $250.00 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:
___ 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 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.
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