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Your Name *

First Name Last Name

Date of birth *

- Month - Day Year

Are you currently studying? *

Yes No

What is the name of your school?

Select your Country of residence *

Select your country of Nationality *

Your E-mail Address *

Alternative E-mai Address

Phone Number *

- Area Code Phone Number

Skype ID

Would you like us to contact you..? *

By phone By mail By skype

What language would you like to learn? *

Please note that you can only study English in Montreal. French courses are available in both cities

In which school would you like to study? *

Montreal Quebec Both

How many weeks would you like to study? *

When would you like to start your course? (Approximate date) *

Month Day Year

What kind or program would you like to take? *

Part-time (18 lessons) Full-time (24 lessons) Intensive (30 lessons) Super Intensive (35 lessons) Bilingual Program (42 lessons) Evening program Summer Camp Winter Camp

What kind or program would you like to take? *

	Part-time (18 lessons)	Full time (24 lessons)	Intensive (30 lessons)	Super Intensive (35 lessons)	Bilingual Program (42 lessons)	Evening program	Summer or Winter Camp
Type of program

Do you need accommodation? *

Yes No

What kind or program would you like to take? *

Homestay (3 meals a day) Homestay (2 meals a day) Homestay (0 meals a day) Student's residence Studio Furnished apartment

What kind of accommodation?

	Homestay (3 meals a day)	Homestay (2 meals a day)	Homestay (0 meals a day)	Student's residence	Studio	Furnished appartment
Select your type of accommodation

Do you require airport pick-up? *

Yes No

Do you require airport drop-off? *

Yes No

Do you require medical insurance? *

Yes No

How did you hear about us? *

Agent Google Facebook Recommendation Information in my school Languages Canada Other

Agency name

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