Application & Registration

* Required

Fill up online or Download Application Form

Where did you hear about Eurocentres Canada? *

PERSONAL INFORMATION

Email *

First Name *

Middle Name (s)

Family Name *

Preferred Given Name *

Gender * Male Female

Date of Birth *

Nationality *

Native Language *

Visa Type * Study Permit Visitor Immigrant Other

If others, please specify

Passport #

Please submit copies of these documents upon arrival

Stay in Canada From *

Stay in Canada To *

Current Address

Street *

City *

Province/State *

Country *

Postal Code / Zip Code *

Emergency Contact Person

Title Mr. Mrs. Ms. Dr.

Name

Relationship

Street

City

Province / State

Country

Postal Code / Zip Code

Telephone #

Fax #

Email Address

STATE OF HEALTH

Illness? Allergies? Medication? Food Exemption? Yes No

If Yes, please specify

Additional Services

Student Guard Medical Insurance Yes
No - (If no, please provide a copy of your insurance on the first day of school)

Start Date

Finish Date

Arrival / Departure Information

Airport Reception Yes No

Name of Airline / Bus / Train

Flight / Bus / Train No

Arrival Date

Arrival Time

Airport Drop-off Yes (If yes, please provide us your departure information on the first day of school)
No

Accommodation Information

Homestay Yes, Full Board Yes, Half Board No

Residence Yes (no meals)
No Accommodations - please include your Vancouver or Toronto address.

If Yes, please specify:

Arrival Date

Departure Date

Do you smoke? Yes No Sometimes

Do you want to live with smokers? Yes No Does not matter

Do you like pets? Yes No

Do you want to live with pets? Yes No Does not matter

Do you like childres? Yes No

Do you want to live with children? Yes No Does not matter

(Eurocentres Canada cannot guarantee any of these requests. We will try our best to accommodate your requests.)

English Assessment

Self Assessment Beginner Intermediate Advanced

English level will be assessed after your arrival. You may apply for extra English Course in addition to Holiday and Career
Programs.

Program Choices

School Location Vancouver Toronto

Start Date

Length of studies

General English Courses (Applicants must be 16 years old or older)

Program Type

Specialized (Elective) Class Add-On (5 lessons per week) Yes No

Pathway, University and Career Programs

Program Type

Holiday & Youth Programs

Program Type

CONSENT AND ACKNOWLEDGMENT

I hereby register for this program declaring, to the best of my knowledge, that all information on this application form is correct. I will notify
the school immediately in the event of any changes to any of this information. I have read and agree to abide by the school’s Dispute
Resolution, Dismissal and Refund Policies which apply to my program(s) in addition to the Homestay regulations (available upon request) and
all other school Accommodation regulations. I also understand that in the event I am registering through a representative or an educational
agency, they may receive compensation from the school. I understand that Eurocentres Canada assumes no responsibility for any
representations, warranties, or agreements made on its behalf which are not solely contained in printed material produced by Eurocentres
Canada. I understand that Eurocentres Canada collects, retains, and uses personal information in accordance to the Personal Information
Protection and Electronic Documents Act (PIPEDA) and the Eurocentres Canada Personal Information and Privacy Code. I am agreeing to the
collection, retention, and use of my personal information by Eurocentres Canada.

I give Eurocentres Canada permission to release any information regarding my program to my education agent and/or family member. * Yes, I agree No, I do not agree

I give Citizenship and Immigration Canada permission to release to Eurocentres Canada any information regarding the status of my Visitor Visa and/or Study Permit. * Yes, I agree No, I do not agree

(By checking No, Eurocentres Canada will not be able to request Visa information on the students behalf.)

I accept the terms of consent and acknowledgment. * Yes, I agree
No, I do not agree (If no, we are unable to process your application.)

PARENT / LEGAL GUARDIAN CONSENT

This section must be completed by the parent or legal guardian of any student under 18 years of age. The participant agrees to participate
in the entire program and will follow safety instructions and all Eurocentres Canada and Eurocentres Canada Host Family Rules and Regulations.
The participant or legal guardian thereof also authorizes Eurocentres Canada and/or Canada Language Camps and/or the Host Family to attain
medical treatment for the participant in the event it is required and agrees to the decisions and instructions given. It is understood that school
staff and the Host Family are not responsible for any medical instructions, decisions and expenses.

Consent From * Parent Guardian

Title * Mr. Ms. Mrs. Dr.

Name *

Telephone # *

Fax #

Email Address

I accept the terms of consent and acknowledgment. * Yes, I agree
No, I do not agree (If no, we are unable to process your application.)

Type the characters you see in the picture below

Registration & Application Form

PERSONAL INFORMATION

STATE OF HEALTH

Additional Services

English Assessment

Program Choices

CONSENT AND ACKNOWLEDGMENT

PARENT / LEGAL GUARDIAN CONSENT

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