International Junior Programs

APPLICATION FORM
Personal Information
Name
Address (Permanent)
Last Street Address State or Province Zip Code First Exactly as it appears on your passport: Middle

MAXIMUM 8 students
per class

All Courses

Female Male City Country

Telephone No. Fax No. Date of Birth Month:

(e.g. January)

E-mail Address Country of Citizenship Day: Year: City and Country of Birth

Emergency Contact
Name Address
Last Street Address State or Province Zip Code First Middle City Country

Telephone No. How did you hear about CISL?

Web site Agency

Relationship
Friend/Relative Previous Student

Other:________________________________________________________________________________

Program Type
New Haven: Los Angeles: LMU Residential LMU Residential + Trip San Diego: USD Residential USD Residential + Trip San Francisco: UC Berkeley Residential Yale Residential Yale Residential+Trip

Summer Residential

Winter Homestay Summer Homestay

Number of Weeks:

San Diego: San Diego:

Winter Homestay Summer Homestay

Winter Homestay + Trip Summer Homestay + Trip

2 weeks

3 weeks

4 weeks
End Date

Note: Please visit our website for 2013 program dates

Start Date

______________/_______/_________
Month Day Year

______________/_______/_________
Month Day Year

English Level

Beginner

Intermediate

Advanced

Arrival & Departure Information

Arrival Departure
Date: _____________/_______/______
Month Day Year

Time:_____________ Time:_____________

Flight No._________ Flight No._________

Date: _____________/_______/______
Month Day Year

CISL 2012 09/20

Accommodations
Homestay University

Number of weeks:__________________ Arrival Date: ____________/_______/______

Month Day Year

Departure Date: ____________/_______/______

Month Day Year

Do you have any allergies or medical conditions?

Yes

No

(If yes, explain)

What are your hobbies/interests?

(Homestay only) Do you like pets? Do you like children? Yes Yes No No

CISL will contact you to confirm your accommodation.

PAYMENT INFORMATION

PLEASE ACCEPT MY PAYMENT OF

$_______________

Payment Method Credit Card No. Billing Address for Credit Card

Bank Wire Transfer

We will contact you with bank wire information

Credit Card (Visa/MasterCard)

Card Holder Name

Expiration Date

I authorize CISL to charge $______________ to this credit card

Credit card authorization signature required

Express Mail delivery of documents is available upon request for $60-$125 depending on your location. This fee is not refundable. Please send my documents by Express Mail
Agreement This agreement is a legally binding instrument when signed by me and accepted by the school. I have read, understood, and agree to the terms and conditions, the refund and cancellation policy, schedule, prices, and starting dates. I confirm that I have sufficient funds to pay all the necessary costs of my course and accommodations during my entire period at C.I.S.L. In case of illness or injury, I grant permission to be examined or treated as necessary. Any questions concerning the school that have not been satisfactorily answered or resolved by the school should be directed to the student's consulate, or the U.S. Immigration Service.

Yes

No

Applicant Signature (Required to process application) E-Signature Option: By checking the box and typing my name above, I confirm that all the information provided in this application is accurate, and that I have read and agree to the terms and conditions listed within this form.

Parent/Guardian Signature (Required if applicant is under 18 years of age) E-Signature Option: By checking the box and typing my name above, I confirm that all the information provided in this application is accurate, and that I have read and agree to the terms and conditions listed within this form.

Photo Release: Students agree to allow photos and video taken during the program to be used for publicity purposes.

Name of Parent/Guardian (if applicable) Date

Please print, sign, and return to CISL San Diego or CISL San Francisco via fax, email, or post. CISL SD Ph: (619) 501-0205 Fax: 619-239-3778 CISL SF Ph: 415-495-7470 Fax: 415-495-7467

CISL 2012 09/20