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* I have read and understood the information page containing the following:
      - Application Procedure
      - Program Fees
      - Refund Policy

General Information

All fields identified by a * must be completed

Date of Application :   Friday, October 21, 2016
I am applying for :* High School
  September or
  February,     Elementary/Middle School
  September     or
How long does the student wish to study for :* 1 year   6 months    Longer      Graduation (English assessment may be required)

Student Information
Student’s Family Name :*  
Student’s Given Name :*  
  (as it appears on passport)
Student’s English Name (if any) :  
Gender :* Male   Female
Date of Birth (day/month/year) :*   / /
Student’s Email:*  
Nationality :*  
Country of Citizenship :*  
Language(s) Spoken :*  
  Other Language(s) :

Parents' Information *
You may complete either the Father’s or Mother’s information or both
Father’s Family Name :  
Father’s Given Name :  
Father's DOB(day/month/yr):*   / /
Father’s Email :*  
Mother’s Family Name :  
Mother’s Given Name :  
Mother's DOB(day/month/yr):*   / /
Mother's Email :*  

Overseas Home Address
Home Address Line 1 :*  
Home Address Line 2 :  
City :*  
Province/State :  
Country :*  
Postal Code :*  
Home Tel :*  
Home Fax :  

Parents' Additional Information *
You may complete either the Father’s or Mother’s occupation information or both
Father’s Occupation :  
Father’s Alternative Phone :  
Father’s Alternative Fax :  
Mother’s Occupation :  
Mother’s Alternative Phone :  
Mother’s Alternative Fax :  

System Access Information
Email :*
check this if more than one person in a family applying and prefer to use the same email address
(a confirmation email will be sent to this email address after completing this online application)
Create your own Login ID
Login ID:* (6-30 characters)
Password :* (6-20 characters, must contain at least one letter and one number)  
Password again to confirm :*  
You can use the combination of the login ID and password above to log back in to update your contact info or complete this application if you can not complete all five sections at one time

Address in Canada (To be used during application process, if applicable)
Address Line 1 :  
Address Line 2 :  
City :  
Province/State :  
Postal Code :  
Tel :  
Fax :  
Email :  

Emergency Contact Person (other than parents)
Family Name :  
First Name :  
Relationship :  
Address Line 1 :  
Address Line 2 :  
Phone :  
Fax :  
Email :  

Academic/Education History & Goals
How many years has the student studied English? *  
I am currently enrolled in Form/Grade :  
  at the following school :
        School Name :  
        Address Line :  
        City :  
        Province/State :  
        Postal Code :  
        Country :  
        Tel :  
        Fax :  
        Name of Principal :  
        Name of English Teacher :  
I am not currently enrolled  
I will be attending School for :* One semester One year
Longer than one year
I wish to :* Graduate in British Columbia
Develop English skills only
When I have completed this program I intend to :* Apply to a Canadian/U.S. college or
Apply to a university or college in my
      home country
Continue to study in my home country


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835 8th Street, New Westminster, BC V3M 3S9 Tel: 1 (604) 517-6285 Fax: 1 (604) 517-6170

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