Family Name*
First Name(s)*
Date of Birth* (mm/dd/yyyy)
Age*
Gender*	Female Male
Nationality*
Father*
Mother*
Street and Number*
City*
State*
Zip/Post Code*
Country*
Home Telephone*
Fax
Email*
Dietary requirements/ restrictions
Allergies
Medications
Smoking Preference*	Non-Smoker Smoker

2. PROGRAMS

Winter Programs
Starting dates	January 6, 2008 January 13, 2008
Number of weeks	2 Weeks 3 Weeks

Summer Programs
	Language plus Activities Language plus Basketball Language plus Golf Language plus Soccer Language plus Tennis
Starting dates	July 1, 2007 July 8, 2007 July 15, 2007 July 22, 2007
Location	Boston Florida
Number of weeks	1 Week 2 Weeks 3 Weeks 4 Weeks

Intensive English Programs
6 Weeks	January 16 May 14 September 4
	Summer: May 14 - August 10 Fall: September 4 - December 7 Spring: January 16 - April 27

How did you hear about us?*
Agent	Friend
Access Website	Other Website (name it, please):
Other:

Level of English*
Beginner	Basic
Intermediate	Upper Intermediate
Advanced

3. ACCOMMODATION

	Dormitory (shared rooms) Homestay (limited availability)
Special request

4. AIRPORT TRANSFER

Airport Transfer	Yes No Group Arrival - Name of group: Airport:
Airline
Flight Number
Date of Arrival
Time	AM PM
Fees: Boston/ Logan Airport = $90 each way. Florida/ Tampa Airport = $50 each way.

5. FINANCIAL STATEMENT and MEDICAL RELEASE

I fully understand the terms, conditions, costs, and cancellation and refund policy as outlined in the General Information and Application Form. I accept full financial responsibility for all costs for tuition, accommodations and personal expenses during my program at ACCESS TO LANGUAGE STUDIES. A NON-REFUNDABLE APPLICATION FEE OF $120 AND A $300 DEPOSIT FEE ARE DUE UPON REGISTRATION. In the event of illness and/or injury I authorize ACCESS TO LANGUAGE STUDIES to take appropriate action for my care. Permission is granted to any appropriate medical center to examine or treat and make necessary referrals to outside physicians as indicated. I further understand that I am required to have accident and health insurance and am responsible for medical expenses incurred. I hereby grant Access to Language Studies permission to use pictures taken of myself during my program, for use on its website and publications.
Name of Student
Date
Name of Parent or Guardian
Date
(Required if student is under 18 years old)

6. GENERAL INFORMATION

COURSE LEVELS AND ORIENTATION

On arrival you will be given a placement test to determine your knowledge of the language, followed by a general orientation. You will then be placed in a class appropriate to your ability level.

ARRIVAL AND AIRPORT TRANSFER

Exact flight information must be provided at least 20 days prior to your arrival. Transfer fees will not be refunded if you fail to inform the school of any changes in your itinerary or if you miss your connections. At all locations you are requested to arrive the Sunday before your beginning session date and depart on the Saturday following your last day of classes. Participants will be invoiced for any additional costs incurred to a prolonged length of stay.

HEALTH FORM

Students are required to have health insurance. ACCESS TO LANGUAGE STUDIES can arrange it for you at a cost of $60 or higher per month. Health Insurance charges are not refundable. Students must fill out the STUDENT HEALTH FORM and present immunization records according to Massachusetts and Florida’s state laws.

I would like to get health insurance through ACCESS TO LANGUAGE STUDIES.

CANCELLATION AND REFUND POLICY

• Cancellation prior to start date:
  • 25% of the program fee will be charged for cancellations made 30 days or more before arrival date
  • 50% of the program fee will be charged for cancellation made 15 days or more before arrival
  • No refunds will be issued for cancellations made 14 days or less before arrival date
• Withdrawal after start date:
  • No refunds will be made for withdrawals after start of the program
• No show: No refund will be issued.
  • All refunds will be processed within thirty (30) calendar days of notification

RELEASE AND AGREEMENT

ACCESS TO LANGUAGE STUDIES and their staff and representatives will not be liable for loss, damage of injury to persons or property howsoever caused by acts of God, war, strikes or government restrictions, terrorist activities, or the acts of omissions of any other parties over which such entities and people have no direct control, including, without limitation, airlines, bus companies, railways, hotels, and sub-contracted agents or tour operators. ACCESS TO LANGUAGE STUDIES reserves the right to cancel a program/tour if enrollment is insufficient, and transfer participants to a comparable location. I agree to abide by ACCESS TO LANGUAGE STUDIES regulations and policies and the directions of my Chaperon and/or ACCESS TO LANGUAGE STUDIES’ personnel during my program. Failure to do so may result in termination of my program immediately, waiving the right to any refunds. I understand that ACCESS TO LANGUAGE STUDIES then may send me home at my own expense. I agree to abide by all local laws, including those concerning drugs and alcohol. I understand that I will pay for any phone calls, personal expenses, and any damage I cause to dorms, facilities, hotels and buses.

By checking this box, I agree to the terms above.

PAYMENT

All fees must be paid in full at least 30 days prior to the student's arrival**. Failure to do so may result in cancellation of the program by ACCESS TO LANGUAGE STUDIES. A non-refundable $120 APPLICATION FEE and a $300 DEPOSIT FEE are required when you first register, in order to confirm your application. Deposit is applicable to remaining balance.

**Any remaining balance will be automatically charged to the credit card above 30 days prior to program starting date.

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