Student Information

Last Name:

First Name:

Male Female

Date of Birth (DD/MM/YY):

Home Address (Number & Street):

Apt/Unit #:

City and Province/State:

Country:

Postal Code:

Home Phone:

e-mail:

Have you or one of your siblings joined us in the past? Yes No

Special Needs

Dietary Needs:

Do you have a medical history or use any medications of which we should be informed:

yes no

If yes please explain:

March Break program Selection

I would like to room with

(if applicable and possible)

Parent/Guardian Information

Name of legal guardian if applicable:

PAYMENT

Comprehensive Travel Insurance
(optional but strongly recommended) $175 (Cancellation & Medical)

Or Optional Cancellation Insurance : $125

I will purchase the travel insurance

yes

no

Once you submit your application, a Payment Form will appear which you must complete and

forward to our office within 5 business days to reserve your space in the program.

A staff member will contact you to acknowledge receipt of your application and payment and to confirm space.

The deposit amount due is $1125 (if you have requested the Comprehensive Travel and Medical Insurance)

$1075 (if you have requested Cancellation ) or $950 (if you have declined insurance), this amount will be deducted from your total balance.

You have the option to pay by VISA, MasterCard or by Cheque and the Payment Form can be faxed, emailed or mailed to our office.

I would like to receive an invoice by:

Email

FAX

Post

I have read the Terms and Conditions and agree to these terms and conditions.