2008 ELS canada Enrollment Contract

Personal Information
Family Name: First Name: Middle Name(s):
   Date of Birth
   Day: Month: Year: 		Gender     Female   Male
Mailing Address
Street Address or
PO Box:
Address Line 2
City:
State/Province:
Country:
Postal Code:
Telephone:
Fax:
Email:
Emergency Contact
Name: Telephone: Relationship:
Additional Information
Where did you hear about ELS Canada?
How many weeks
will you study? 		4 8 12 16 20 24 Other (min. 2 weeks)
Course Selection: Intensive Semi-Intensive Other
Location: Vancouver Toronto
Please indicate the date you wish to commence study - regular session start dates:
Jan 14 Feb 11 Mar 10 Apr 7 May 5 June 2 June 30
July 28 Aug 25 Sept 22 Oct 20 Nov 17 Dec 15 Other:
Please Note: All sessions begin on a Monday, except * due to a National Holiday.
Application Fee - CDN $100         Optional Courier Charge - CDN $75 Yes No
Tuition Fees - all prices in Canadian $
Intensive Program Semi-Intensive Program
# of Sessions Weeks Tuition Approx. Discount # of Sessions Weeks Tuition Approx. Discount
1 4 1320 0% 1 4 970 0%
2 8 2640 0% 2 8 1940 0%
3 12 3762 5% 3 12 2765 3%
4 16 4752 10% 4 16 3492 10%
5 20 5940 10% 5 20 4365 10%
6 24 6732 15% 6 24 4947 15%
7 28 7854 15% 7 28 5772 15%
8 32 8448 20% 8 32 6208 20%
9 36 9504 20% 9 36 6984 20%
.5 2 792 0% .5 2 582 0%
.75 3 1056 0% .75 3 727.50 0%
Health Insurance I will require health insurance
(arranged on Day 1 at the school - $2/day) 		I will provide my own health insurance (proof must be shown on Day 1 at ths school)
Financial and Health Statement / Information Release

By clicking "Submit" below, I certify that the information contained herein is accurate and correct to the best of my knowledge. I have read and hereby accept all ELS Language Centers' terms and conditions. I understand that my expenses (excluding personal miscellaneous expenses) per session while studying at ELS Language Centers will be as indicated on the chart above for the course selected. I agree to accept full responsibility for these expenses. In case of illness and/or injury, permission is granted to any appropriate medical centre to examine or treat and make necessary referrals to outside physicians as indicated. Permission is also granted to release information regarding applicant's health to other designated individuals. I authorize ELS Language Centers to release information regarding my studies to my sponsoring agency or my guardian whose name appears below.

I have read and understood the above statement.
I have read and understood the ELS Terms and Conditions.
I am 18 years old or older.
I am less than 18 years old. This application is being submitted by my parent or guardian.
Name of Guardian (if applicant is under 18)
homestay
Do you want ELS to arrange your homestay? Yes No
(If you choose "YES", you must fill out the homestay application after submitting this form.)