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ApplicationForm

embassysummer.com

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Application orm 2013Fill in all sections o the orm and return via email to your Advisor. Please print clearly in English and in BLOCK letters.

Dont have an Advisor yet? Please go to www.embassysummer.com/book, ll out the orm and you will be assigned an Advisor.

Booking or more than one child? Please ll out a orm or each.

Need help with the orm? Call +44 1273 339 400

About the student

Family name

First names

Date o birth (dd/mm/yyyy)Age

Gender: M F Nationality

Country o birthYour own language

Home address

Country

Zip/post code

Passport number

Mobile number

Telephone (parent)

Parent mobile number

Email address

How did you hear about Embassy Summer?

Who will be paying or your course? Yoursel Parents Company Company name:

What is your present level o English? Beginner Elementary Pre-intermediate Intermediate Upper-intermediate Advanced ProcientWill you be applying or a visa? Yes No

Course and accommodation options

Please check that the accommodation options are available in the centre o your choice (see page 4 o this orm)

There is space below or you to add a second centre i you wish.

Preferred centre

CentreAccommodation type: Standard En suite Homestay Residential

Start and nish date

Number o weeks

Second choice

CentreAccommodation type: Standard En suite Homestay Residential

Start and nish date

Number o weeks

Do you smoke? Yes No

Do you have any allergies, medical conditions or special requirements (e.g. allergies, vegetarian)? Yes No I yes, please give details:

StudyCare health, medical and travel insurance

Do you require StudyCare insurance? Yes No, I have alternative cover and do not require StudyCare insurance

Countryper

weektwo

weeksour

weekssix

weekseight

weeksthree

monthsour

monthsfve

monthssix

monthsseven

monthseight

monthsnine

monthsone

year

UK 8

USA 96 139 194 244 337 417 503 581 660 739 818 962

Canada 14

Australia* 99 197 296 395

Currency

UK: GBP Canada: CAD USA: USD Australia: AUD

*The Australian Government requires all overseas students studying on a Student Visa to have Overseas Student Health Cover (OSHC).

It is important that your cover is maintained or the duration o your program/s. The ee or OSHC is payable at the time you conrm your enrolment.

Discount rates apply or two years or more (Administration ee included). Full list o prices available online at embassyenglish.com

University

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Airport transfers

We recommend that you book fights only ater your course is conrmed. I you dont have fight details at this stage you can send these to us later.

Do you require transers to and/or rom the airport (available as listed in the tari)? Arrival only Departure only Both ways Not required

Arrival dateTime

Departure airport

Arrival airport

Flight no.

Departure dateTime

Departure airport

Arrival airport

Flight no.

Payment method

Payment is made in two installments. First a small enrolment fee then the full balance. There are two ways you can make a payment,

by credit card or bank transer. Our preerred method is by credit card. I you choose this our advisor will send you a secure online payment link.

I you wish to pay by bank transer your advisor will send you our bank details.

Enrolment fee

This is taken at the time o booking. No money will be charged until your place is conrmed. I no places are available, we will provide alternatives,

or reund your money. Only when your place is conrmed and you proceed with the booking, does this ee become non-reundable.

Country UK USA Canada Australia

Enrolment ee 95 160 160 242

Please tick which applies

Please indicate your preerred method o payment:

Credit card (via secure online link)

Bank transer* *USA subject to a USD25 bank ee, Canada subject to a CAD10

Full balance

The ull balance or your course (and any extras such as transers and insurance) is required at least two weeks beore you arrive.

Please indicate your preerred method o payment:

Credit card (via secure online link)

Bank transer* *USA subject to a USD25 bank ee, Canada subject to a CAD10

Agreement statement o parent/guardian

1 I have read and understood the terms and conditions outlined in the relevant

Embassy terms and conditions o enrolment documentation, including the

cancellation and reund policy.

2 I have read and understood the relevant schedule o costs set out in the current

Embassy price lists and hereby arm that I have sucient unds to pay or all

tuition costs as well as the cost o all ood, accommodation and all other

personal expenses during the ull period o my course at Embassy.

3 I authorise Embassy to take appropriate action in the event o a medical

emergency and I understand that I am responsible or all medical bills incurred.

4 I certiy that all the inormation given by me in this enrolment orm is accurate

and complete.

Signature o applicant

Date

Signature o parent or guardian

Date

Relationship to applicant

I the applicant is under 18, a parent or guardian who, in doing so, agrees to all Embassy conditions, must sign this orm and guarantee the necessary unds or the applicant.

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Tari 2013

14910_SEA 10.12

Centre Accommodation Price One way transer

Australia

Brisbane Homestay 1340 289 (OOL) 144 (BNE)

Surers Paradise Homestay 1340 144 (OOL)

UK LGW LHR STN LTN Central London

BedordStandard 610 150 125 123 72 160

En suite 645 150 125 123 72 160

Bristol En suite 625 230 210 60 (BRS) 160 (BHX) 260

CambridgeHomestay 600 190 165 95 95 165

Residential 685 190 165 95 95 165

CanterburyStandard 615 143 171 171 195 195

En suite 650 143 171 171 195 195

Chalont Standard 640 125 80 160 160 90

ChichesterStandard 610 95 102 160 115 121

En suite 630 95 102 160 115 121

Docklands En suite 685 122 94 122 141 45

Hastings Homestay 575 105 140 150 150 140

KingswoodStandard 615 88 46 168 160 87

En suite 650 88 46 168 160 87

Medway En suite 660 95 116 132 145 122

Mile End En suite 685 122 94 122 141 45

Oxord Headington Standard 645 136 97 150 140 135

Oxord Wheatley Standard 620 136 97 150 140 135

Reigate Standard 620 64 90 117 119 76

South Bank En suite 680 122 94 122 141 45

Southsea En suite 625 106 106 160 115 121

UCL Standard 680 122 94 122 141 45

UxbridgeStandard 640 125 77 160 160 52

En suite 665 125 77 160 160 52

USA

Boston Dean Standard 1180 155 (BOS)

Boston Emmanuel Standard 1180 140 (BOS)

Boston Tuts Standard 1180 140 (BOS)

Fort Lauderdale DowntownHomestay 1154

82 (FLL) 125 (MIA)Residential 1180

Manhattan Pace Standard 1405 170 (JFK)

Los Angeles Cal State Northridge Standard 1200 160 (LAX)

Los Angeles Occidental Standard 1180 160 (LAX)

Los Angeles Woodbury Standard 1180 160 (LAX)

New York Long IslandNot air conditioned 1210 170 (JFK) 210 (EWR)

Air conditioned 1241 170 (JFK) 210 (EWR)

New York Rutgers Standard 1241 210 (JFK) 160 (EWR)

New York Storm King Standard 1154 250 (JFK)

San Diego Homestay 1154 104 (SAN)

San Francisco Santa Clara Standard 1180 160 (SFO)

Canada

Toronto Homestay 1128 132 (YYZ)

Victoria Homestay 1128 100 (YYJ)

BOS - Boston Logan

FLL - Fort Lauderdale

MIA - Miami International

LAX - Los Angeles International

EWR - New York Newark

JFK - New York John F Kennedy International

SAN - San Diego International

SFO - San Francisco International

LGW - London Gatwick

LHR - London Heathrow

STN - London Stanstead

LTN - Luton

BRS - Bristol

BHX - Birmingham

BNE - Brisbane International

OOL - Gold Coast Coolangatta

Canadian airport codes

YYZ - Pearson International

YYJ - Victoria International

US airport codes UK airport codes Australian airport codes

CurrencyAustralia: AUD UK: GBP USA: USD Canada: CAD