IPSA - International Partners for Study Abroad

English Language School in Hawaii, USA.
Online Secure Application Form.


Part A. Personal data:


Mr/Mrs/Ms/Miss


First Name:


Last Name:


Home Address:

Street Address:


City:


State/Province:


ZIP (Postal) Code:


Country:


Day Telephone Number:


Evening Telephone Number:


E-mail:


Fax: [optional]


Date of Birth: month day year            Male Female

Place of Birth (country, city):   

Citizenship (country):

Passport Number:


Nationality:


Your native language:


Other languages, if any:


I am currently: a college/university freshman sophomore junior senior
Graduate Student High School Senior Interested Adult Professional

If you are a graduate or undergraduate student, please provide the following information:

Current college/university/graduate school:

My major field of study:       GPA

If you are a professional, please specify your profession and company:

Profession:

Please enter the address of your college, university or company:






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. The School now requires all students to have health insurance.

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
If no, on which Visa do you intend to enter the United States?

Do you request Express courier service to send you an I-20 for a student Visa? Yes No
If yes, an additional fee for this service will apply.





Part B. Program data.



I Wish to Start Classes on (Day) (Month) (Year)

(You can start classes on any Monday.)

How Many weeks do you plan to attend?     Please enter a number of weeks:

I want to register for the following program: (Please select a program below)

Intensive English Program (IEP), 25 lessons a week
Super Intensive English Program (IEP), 35 lessons a week
Academic Year Program (36 weeks) 25 lessons a week

Short Term English Program Program (STEP), 20 lessons a week

Conversation Cafe

Intensive English Program for Executives, 35 lessons per week

Cambridge Exam Preparation (FCE and CAE), 9 weeks
Cambridge Exam Preparation (FCE and CAE), 12 weeks

Summer ESL Program for Kids (K-STEP)
Summer ESL Program for Teens (J-STEP)

Private Tuition Lessons per week.

If you have selected Private Tuition, please enter your requirements for Specialization (General English, Business English, TOEFL/TOEIC preparation, Pronunciation, Writing, etc.) in the Comments text area below.

Course Comments:


I have studied English for  Years at a 
(type of school e.g. high school, university, private language school, other)

What is your level of English?
    Zero Beginner
    Elementary
    Pre-Intermediate
    Intermediate
    Advanced


Accomodations.

Do you need accommodation?      Yes      No 

Note: Short-term (less than 6 months) accommodation prices in Honolulu vary greatly due to the type of accommodation (hotel, condo, hostel, apartment, etc.), seasonal factors (Winter is high season), location and condition of the building (near beach?, new building?, swimming pool?), size of rooms (studio?, 1-bdrm?), and furnishings provided (kitchen?, kitchenette?, television?, study desk?)

What type of accomodation would you prefer?

Hotel

Hostel

Condominium

Host Family

Please enter below your accommodation requirements including price range and/or preferences:



Do you require airport pickup?     Yes.     No.

**Arrival date:      **Time:

**Airline and 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 $100, course registration of $150 and the Tuition Deposit of $250 has been received. If you apply for K-STEP or J-STEP summer program, your payment of activity fee ($270 per week) is also required with your application.

Please note that you may apply online only if you pay the enrollment fees and the tuition deposit by credit card.

If you are going to pay by a certified check, money order or by wire transfer, please click here to access a monospaced Application Form, print it out from your browser and send it with your payment by post or by fax (if you make your payment by wire transfer).


Payment by Credit Card

We accept VISA and MasterCard. In this Form, we utilize the Secure Socket Layer (SSL) authentication and RC4 128 bit encryption technology. SSL encryption protects information being transmitted across the internet to our processing center.
Please select payment option below:

Please charge the application fee of $100, registration fee of $150.00 and the tuition deposit of $250.00 and if I apply for K-STEP or J-STEP summer program, please also charge activity fee ($270 per week) for the total number of weeks I want to book, to my credit card provided below.

Please charge the enrollment fees and the full payment to my credit card provided below.

Even if you select a "full payment" option, we will charge only the application and registration fees and the tuition deposit at the time of accepting your application and will process the payment of the balance to your credit card after registering you for the course. Please also note that if you would prefer to pay the balance by credit card, a 4.5% convenience payment processing service fee will be included in the invoice. There are no any additional charges on your payment of the application and registration fees and deposits by credit card.

To process your payment using Visa or MasterCard, please fill in the fields below with the requested information EXACTLY as it appears on your monthly bankcard statement.

Please select credit card:


Cardnumber:


Expiration Month:


Expiration Year:


Card Verification Value:
The last three digits on the back of your credit card after the credit card number. This value protects you from online fraud by verifying that you are in possession of the card you are attempting to use.


Cardholder Billing Information:

Cardholder Name:


Street Address:


City:


State:


Zip Code:



Please double-check the above credit card information.





Part D. Autobiographical Essay.

Please write a brief essay. This essay must contain a short story of your life and experience, and reasons why you wish to study abroad.






Part E. Agreement and release.

By submitting 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 Study Abroad International 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 assume all risks and responsibilities and discharge IPSA and the study abroad program host and all their officers, agents and employees from and against any and all claims of damage to personal property or personal injury which may result from my enrollment and participation in the study abroad program host courses, excursions, and/or on and off-campus activities. I have read all terms and conditions and rules and agree to follow all IPSA and study abroad host procedures and regulations. 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.

Yes, I agree. I don't agree


Please click on the button to submit the Application: