REGISTRATION FORM

Mr. Student Information Last Name Nationality Home Address City Country Email Agent Information Agency Contact Person Arrival Information Arrival Date Flight Information Accommodation Homestay (HS) Length Weeks Type Special Requests or Preferences Residence SINGLE TWIN HS No Accommodation Ms. Campus: Toronto Vancouver First Name Mother Tongue Date of Birth Telephone Province Passport Number

Email Airport Pick Up Airport Drop Off YES YES NO NO

ILAC will do our best to accommodate your requests, however, due to availability we cannot guarantee that your request will be granted.

Medical Information: Please note it is mandatory for ILAC students to have Medical Insurance during their stay in Canada Do you have medical insurance YES NO Policy Number If NO, will you buy it from ILAC? YES NO Passport Number Do you have allergies? YES NO List Allergies Do you have medical problems? YES NO List Medical Issues Do you have food restrictions? YES NO List Food Restrictions Do you smoke? YES NO Telephone

Canada is mostly a smoke-free environment but you are permitted to smoke outdoors in designated areas.
Program Information Power English Course Focus Intensive English General English ___ Cambridge (FCE & CAE) ___ TOEFL Preparation ___ IELTS Preparation ___ Business English ___ Pre Degree I ___ Start Date

Pre-Degree II Pre-Degree III Certificate High School TESOL GMAT Preparation Coop, Internship, Career Program

___ ___ ___ ___ ___ ___

Other Program

Weeks of Study

I have read and agree to the Policies and Procedures as outlined in the Student Handbook and understand my Student Rights and Responsibilities while attending at ILAC. I hereby certify the above information is true and complete. I understand that any false or incomplete information submitted in support of my registration may invalidate my registration. If the applicant is less than 18 years old, please have a parent co-sign below. To review the current student handbook visit www.ilac.com. Applicant Signature: __________________________ Date: __________________________ Co-applicant Signature: _______________________ Date: _______________________
ILAC REGISTRATION FORM 2013