S​aanich​ E​nglish​ L​anguage​ S​ummer​ A​cademy – ​www.selsa.

ca

Registration Form (three week program)

Student: ​Please ​print clearly​ and spell name the same as in passport
Last Name:

First Name:

Date of Birth: Country of Citizenship: Gender:

(DD / MM / YYYY )

E-mail: Phone number:

Level of English skills:

​Beginner Lower-Intermediate High-Intermediate Advanced

For how many years have you studied English? ​ ___________

Do you have a learning disability? ​(such as ADD/ADHD, Dyslexia, etc.) ​ Yes ​ ​No
If yes, please explain:
_________________________________________________________________________________

Describe your personality:

outgoing shy organized ​disorganized
like to talk quiet like to be active ​like to study
independent friendly don’t worry much ​easily worried

What activities do you enjoy? What sports do you play? Do you play any musical
instrument(s)?
_________________________________________________________________________________
_________________________________________________________________________________

Name of Brother(s) and Sister(s): Gender: Living at Home?

Age:

Yes No

Yes No

Yes No

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 S​aanich​ E​nglish​ L​anguage​ S​ummer​ A​cademy – ​www.selsa.ca
Have you ever spent time apart from your family? Yes ​No
If yes, please describe:
_________________________________________________________________________________
_________________________________________________________________________________

How well will you be able to adjust to a different environment, language, foods and customs?

____ Very well, I am not worried at all.

____ I am a little worried about adjusting.
____ I am worried about adjusting.
____ I am very worried about adjusting.

Please describe any worries or concerns you have:

_________________________________________________________________________________
_________________________________________________________________________________
Do you have any pets? No ​Yes
Dog(s) ​Cat(s) Other: _________________________

Do you smoke cigarettes? Yes ​No

If yes, please note that smoking is prohibited is any public buildings in British Columbia. This does include all of
our schools and school grounds. Most host families will not permit smoking in the house.

Do you have any allergies? Yes ​No

Medications: ______________________________________________
Food: ___________________________________________________
Animals: _________________________________________________
Other: ___________________________________________________
If yes, please clearly indicate substance you are allergic to and severity of reaction.
Are you a vegetarian? Yes ​No
Are you a Vegan? Yes ​No

Are there any other dietary concerns/restrictions we need to know? Yes ​No
If yes, please describe:

_________________________________________________________________________________
_________________________________________________________________________________

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 S​aanich​ E​nglish​ L​anguage​ S​ummer​ A​cademy – ​www.selsa.ca

Medical History
Do you currently have any on-going health concerns/illnesses? Yes No
If yes, please explain:
_________________________________________________________________________________
_________________________________________________________________________________

Do you take any medication regularly? Yes No

If yes, please describe (include name of medication, frequency, dosage):
________________________________________________________________________

Date of last tetanus shot:​ _____________________________________

Indicate with an ‘X’ if you have had any of the following illnesses:
Asthma Eczema Rheumatic Fever
Cancer / Tumors Hepatitis Rubella
Chicken Pox Measles Scarlet Fever
Convulsive Disorder Migraine Headaches Thyroid Disease
Diabetes Mumps Ulcer
Eating Disorder Pertussis (whooping cough) Other: ___________________________

Please provide approximate dates for any illnesses indicated above:

_________________________________________________________________________________
_________________________________________________________________________________

Do you currently suffer from any of the following? ​(Please include letter from doctor)

Asthma Celiac Disease Digestive troubles Diabetes

Frequent headaches Heart problems Respiratory problems Epilepsy
Eczema / Skin disorder Vision problems Other __________________

Please provide detailed information for any condition indicated above:

_________________________________________________________________________________
_________________________________________________________________________________
Do you have any physical restrictions or limitations? Yes ​No
If yes, please describe:
_________________________________________________________________________________
_________________________________________________________________________________

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 S​aanich​ E​nglish​ L​anguage​ S​ummer​ A​cademy – ​www.selsa.ca
Medical Insurance Information
The student needs to be able to provide proof of medical insurance. ​(Required for all international students, recommended for
Canadian students)

Name of Insurance Company: ________________________________________

Insurance Policy Number: ___________________________________________
Insurance Company Telephone Number: _______________________________

Contact Information for Student and Parents

Permanent Address of Student:

#, Street, Apt.:

City, Province (state):

Postal Code: Country:

Home Telephone ​(include country and area code)​:

Father (or legal guardian – if applicable):

Last Name: First Name:

Home Telephone: Work Telephone:

E-mail: Cell Phone:

Mother (or legal guardian - if applicable):

Last Name: First Name:

Home Telephone: Work Telephone:

E-mail: Cell Phone:

Emergency contact: ​(in case we cannot contact parents)

Last Name: First Name:

Home Telephone: Work Telephone:

E-mail: Cell Phone:

Relationship to student:

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 S​aanich​ E​nglish​ L​anguage​ S​ummer​ A​cademy – ​www.selsa.ca
Travel Information
(All travel arrangements must be made to and from Victoria, BC)
Date Time Where
Arrival Airport Flight #: ________________
Swartz Bay Ferry Terminal
am pm
Departure Airport Flight #: ________________
Swartz Bay Ferry Terminal
am pm

Letter of Introduction to the Host Family

Student Name: ____________________________________________________
(In this space please write a letter of introduction to your host family. What would you like them to know about
you? Why are you coming to SELSA? What are you hoping to do and/or achieve while at SELSA?)

__________________________________________________________________________________
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__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

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Authorization for Medical Treatment and/or Hospitalization

In case of emergency, if I am not able to be present, I authorize the doctor chosen by the director(s) of
the program or by his/her representative to hospitalize my child; to ensure my child receives adequate
medical care; and, as needed, prescribe medications, administer injections and anesthesia, and
undertake surgical intervention.

______________________________________ ____________________
Signature of Parent or Guardian Date

Authorization to Disclose Personal Information

We, the student and parent/guardian, understand that by signing below we agree to and understand
that:

1. During the course of the program the student may be photographed during activities and asked for
comments/feedback about the program by SELSA staff. These may be used for promotional purposes.

2. The information provided in the application form will be shared with the student’s host family.

3. The student’s name and basic contact information may be shared with the student partner in the
host family's home. This is done solely so that the students may have contact prior to arriving to help
lessen some of the fears and anxieties they may have.

______________________________ ________________________________
Signature of student Signature of parent/guardian

Waiver of Responsibility
We, the undersigned, state that we have read, understand, and accept all of the ​Expectations and Rules of the
SELSA program, agree to the ​Terms and Conditions ​and the ​Personal Conduct and Code of Ethics​.
We understand that should the student be expelled from the program due to non-conformity to rules and
expectations, we are solely responsible for any costs (i.e. airfare) associated with the early departure and return to
the student’s permanent residence.

We, the undersigned, will not hold ​Saanich English Language Summer Academy (SELSA) LTD,​ its officers,
shareholders, employees, or the host family responsible for any legal, moral, physical, or financial problem(s) that
our child may cause by not conforming to the rules and expectations of SELSA, or to the laws in effect in the
province of British Columbia and in Canada.

Signatures:

Signature of Student: ___________________________ Date: ______________

Parent/Guardian:_______________________________ Date: ______________

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 S​aanich​ E​nglish​ L​anguage​ S​ummer​ A​cademy – ​www.selsa.ca
Your son/daughter may participate in activities that involve risks, dangers and hazards. These activities may include,
but are not limited to the following:
● Kayaking and stand up paddle boarding​ provided by operator “Ocean River Sports.”
● Dragon Boating​ provided by operator “Fairway Gorge Paddling Club”
● Mid Island Camping and Caving Excursion​ provided by operators “Island Pacific Adventures Ltd” and
“RLC Park Services.”
● Escape games ​provided by operator “Quest Reality Games.”
● Other activities​ as deemed appropriate by the SELSA Program
All operators require the parent/guardian to sign a waiver before a student is allowed to participate. Please read
carefully! By signing below you also understand that capacity for some activities is limited and your son/daughter may
not be able to participate in all of his/her chosen activities.

RELEASE OF LIABILITY, WAIVER OF CLAIMS, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT

Please note that by signing this agreement, you give up the right to sue for any injury or damages, howsoever
caused.

TO: ​Operator of above listed activities (the “Company”) ​and their directors, officers, employees, representatives and agents.

I ​(Parent’s name)​ _________________________________ ​ hereby sign this agreement on behalf of my child, his/her
personal representatives, heirs and assigns. I hereby authorize the SELSA Program Directors (Chris McFarland or
Kristi Timmermans) or their designate to sign any other required waiver forms on my behalf.

1. I agree as a precondition to my child’s participation in all events organized by “the Company” and/or “the Agents”
including, but not limited to the listing above and any other activity occurring at the Operators but not mentioned above
(collectively referred to as “the Activities”) and in further consideration of “the Company” allowing my child to do so,
that I will be strictly bound by the terms of this Release of Liability, Waiver of Claims, Assumption of Risk and
Indemnity Agreement (“the Agreement”).

2. I acknowledge that “the Activities” involve inherent risks and dangers that may cause serious injury and possible
death to participants.

3. I fully understand the risks and dangers associated with my child’s participation in “the Activities” and accept same
entirely at my child’s and my own risk.

4. I hereby waive any and all claims which I may have against “the Company” and “the Agents” and release “the
Company” and “the Agents” from all liability for injury, death, property damage or any other loss sustained by my child
as a result of his/her participation in “the Activities”, due to any cause whatsoever; including negligence, breach of
contract, or breach of any statutory or other duty of care by “the Company” and/or “the Agents”.

5. I appreciate that “the Agreement” limits the liability of “the Agents” to the same extent as it limits the liability
of “The Company”, even though “the agents” are not formal parties to “the Agreement”.

I HAVE READ AND UNDERSTAND “THE AGREEMENT”, I UNDERSTAND THAT THIS DOCUMENT CONTAINS A
PROMISE NOT TO SUE “THE COMPANY” AND/OR “THE AGENTS” AND THAT IT CONSTITUTES A RELEASE OF
LIABILITY AND INDEMNITY FOR ALL CLAIMS. ​I AM THE PARENT AND/OR GUARDIAN ​OF THE PARTICIPANT
AND I HAVE READ AND UNDERSTAND AND EXECUTE “THE AGREEMENT” ON BEHALF OF MY CHILD.

Name of Child: _________________________________________________ Date: _________________________

Name of Parent: ____________________________ Signature of Parent: _______________________________

Name of Witness: ___________________________ Signature of Witness: ______________________________

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