embassysummer.

com

Application Form

Application form 2013

Fill in all sections of the form 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, fill out the form and you will be assigned an Advisor. Booking for more than one child? Please fill out a form for each. Need help with the form? Call +44 1273 339 400

About the student

Family name Date of birth (dd/mm/yyyy) Country of birth Home address Country Passport number Telephone (parent) Email address How did you hear about Embassy Summer? Who will be paying for your course? Yourself What is your present level of English? Beginner Will you be applying for a visa? Yes No Zip/post code Mobile number Parent mobile number First names Age Gender: M F Nationality

Your own language

University
Parents Company Company name: Intermediate Upper-intermediate Advanced Proficient

Elementary

Pre-intermediate

Course and accommodation options

Please check that the accommodation options are available in the centre of your choice (see page 4 of this form) There is space below for you to add a second centre if you wish. Preferred centre Centre Start and finish date Second choice Centre Start and finish date Do you smoke? Yes No No If yes, please give details: Accommodation type: Standard Number of weeks En suite Homestay Residential Accommodation type: Standard Number of weeks En suite Homestay Residential

Do you have any allergies, medical conditions or special requirements (e.g. allergies, vegetarian)? Yes

StudyCare health, medical and travel insurance

Do you require StudyCare insurance? Yes Country
UK USA Canada Australia*

No, I have alternative cover and do not require StudyCare insurance six weeks
194

per week
8 14

two weeks
96

four weeks
139

eight weeks
244

three months
337 99

four months
417

five months
503

six months
581 197

seven months
660

eight months
739

nine months
818 296

one year
962 395

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 for the duration of your program/s. The fee for OSHC is payable at the time you confirm your enrolment. Discount rates apply for two years or more (Administration fee included). Full list of prices available online at embassyenglish.com

Airport transfers
We recommend that you book flights only after your course is confirmed. If you dont have flight details at this stage you can send these to us later. Do you require transfers to and/or from the airport (available as listed in the tariff)? Arrival only Arrival date Departure date Time Time Departure airport Departure airport Departure only Arrival airport Arrival airport Both ways Not required Flight no. 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 transfer. Our preferred method is by credit card. If you choose this our advisor will send you a secure online payment link. If you wish to pay by bank transfer your advisor will send you our bank details. Enrolment fee This is taken at the time of booking. No money will be charged until your place is confirmed. If no places are available, we will provide alternatives, or refund your money. Only when your place is confirmed and you proceed with the booking, does this fee become non-refundable. Country
Enrolment fee Please tick which applies

UK
95

USA
160

Canada
160

Australia
242

Please indicate your preferred method of payment: Credit card (via secure online link) Bank transfer* *USA subject to a USD25 bank fee, Canada subject to a CAD10 Full balance The full balance for your course (and any extras such as transfers and insurance) is required at least two weeks before you arrive. Please indicate your preferred method of payment: Credit card (via secure online link) Bank transfer* *USA subject to a USD25 bank fee, Canada subject to a CAD10

Agreement statement of parent/guardian

1 I have read and understood the terms and conditions outlined in the relevant Embassy terms and conditions of enrolment documentation, including the cancellation and refund policy. 2 I have read and understood the relevant schedule of costs set out in the current Embassy price lists and hereby affirm that I have sufficient funds to pay for all tuition costs as well as the cost of all food, accommodation and all other personal expenses during the full period of my course at Embassy. Signature of applicant 3 I authorise Embassy to take appropriate action in the event of a medical emergency and I understand that I am responsible for all medical bills incurred. 4 I certify that all the information given by me in this enrolment form is accurate and complete.

Date

Signature of parent or guardian

Date

Relationship to applicant
If the applicant is under 18, a parent or guardian who, in doing so, agrees to all Embassy conditions, must sign this form and guarantee the necessary funds for the applicant.

Tariff 2013
Currency Australia: AUD UK: GBP USA: USD Canada: CAD Centre
Australia Brisbane Surfers Paradise UK Bedford Bristol Cambridge Canterbury Chalfont Chichester Docklands Hastings Kingswood Medway Mile End Oxford Headington Oxford Wheatley Reigate South Bank Southsea UCL Uxbridge USA Boston Dean Boston Emmanuel Boston Tufts Fort Lauderdale Downtown Manhattan Pace Los Angeles Cal State Northridge Los Angeles Occidental Los Angeles Woodbury New York Long Island New York Rutgers New York Storm King San Diego San Francisco Santa Clara Canada Toronto Victoria
US airport codes BOS - Boston Logan FLL - Fort Lauderdale MIA - Miami International LAX - Los Angeles International EWR - New York Newark

Accommodation

Price

One way transfer

Homestay Homestay Standard En suite En suite Homestay Residential Standard En suite Standard Standard En suite En suite Homestay Standard En suite En suite En suite Standard Standard Standard En suite En suite Standard Standard En suite Standard Standard Standard Homestay

1340 1340 610 645 625 600 685 615 650 640 610 630 685 575 615 650 660 685 645 620 620 680 625 680 640 665 1180 1180 1180 1154 1180 1405 1200 1180 1180 1210 1241 1241 1154 1154 1180 1128 1128

289 (OOL) 144 (OOL) LGW 150 150 230 190 190 143 143 125 95 95 122 105 88 88 95 122 136 136 64 122 106 122 125 125 155 (BOS) 140 (BOS) 140 (BOS) 82 (FLL) 170 (JFK) 160 (LAX) 160 (LAX) 160 (LAX) 170 (JFK) 170 (JFK) 210 (JFK) 250 (JFK) 104 (SAN) 160 (SFO) 132 (YYZ) 100 (YYJ)

144 (BNE) LHR 125 125 210 165 165 171 171 80 102 102 94 140 46 46 116 94 97 97 90 94 106 94 77 77 STN 123 123 60 (BRS) 95 95 171 171 160 160 160 122 150 168 168 132 122 150 150 117 122 160 122 160 160 LTN 72 72 160 (BHX) 95 95 195 195 160 115 115 141 150 160 160 145 141 140 140 119 141 115 141 160 160 Central London 160 160 260 165 165 195 195 90 121 121 45 140 87 87 122 45 135 135 76 45 121 45 52 52

Residential
Standard Standard Standard Standard Not air conditioned Air conditioned Standard Standard Homestay Standard Homestay Homestay

125 (MIA)

210 (EWR) 210 (EWR) 160 (EWR)

UK airport codes 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

Australian airport codes BNE - Brisbane International OOL - Gold Coast Coolangatta Canadian airport codes YYZ - Pearson International YYJ - Victoria International

14910_SEA 10.12