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REGISTRATION FORM

Family name*
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First name*
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Street address*
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Province*
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City*
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Postal Code*
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Country*
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Telephone
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Fax
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E-Mail Address*
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Date of birth
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Sex*
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 Male Female
Nationality
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Native language:
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Interests:
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Agent name (if applicable)
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Course Start
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Course Duration:
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Course Type
20-hour social
25-hour Conversation
30-hour Academic
 
Deluxe Fluency
Private Tuition # of hours
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What is your approximate level of English? *
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Accommodation required? *
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 Yes No
 
If no, contact person in Canada
Contact name
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Contact telephone
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Accommodation start date
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Accommodation end date
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Please state any dietary needs
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Can you live with children? *
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 Yes No
 
Do you smoke? *
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Can you live with pets? *
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 Yes No
 
Other homestay requirement
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Travel information:
Arrival date:
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Airline and flight #
(if available)
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Arrival time
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Do you want someone from Village English to meet you at the Airport? *
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 Yes No
Do you require insurance coverage? *
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 Yes No
 
*I have read and understood the Refund Policy and I understand that by submitting this form I am bound by all Village English policies. * Yes No
* Mandatory field
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