ESC Registration Form
 
Personal Information
*First Name:
*Last Name:
*Email:
*Gender:
*Birthdate (MM/DD/YYYY):
*Citizenship:
   
Home Address:
*Street:
*City:
*Province/State:
*Postal Code:
*Country:
*Telephone:
Fax:
 
Emergency Contact Information
Name:
Phone Number:
Location of Emergency Contact Canada Home Country
 
What program do you want to take?
*Your level:
*Starting Date (MM/DD/YYYY):
Finishing Date (MM/DD/YYYY):
*Number of Weeks:
 
Course:  
General English Programs
Special Programs
Internship Programs
Teen Programs
 
Accommodation Registration
*Would you like accomodations: Yes No
How many meals per day?
 
Expected homestay dates:
Starting Date (MM/DD/YYYY):
Finishing Date (MM/DD/YYYY):
Number of Weeks:
*Would you like Airport pickup? Yes No
Airline:
Date (MM/DD/YYYY):
Flight #:
Time of arrival:

Please answer the following questions to assist us in your homestay placement:
Do you smoke? Yes No
Do you have any allergies or medical concerns? Explain.
Do you have any special dietary needs? Explain.
Can you live with cats? Yes No
Can you live with dogs? Yes No
Can you live with small children? Yes No
What are your hobbies?

 I confirm that I have read and I accept the Conditions of Enrollment as well as the Refund Policies of the English School of Canada as stated in the registration kit.

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English School of Canada
79 St. Clair Ave. E.
Suite 202
Toronto, Canada, M4T 1M6
Tel: (416) 686-1596
Fax: (416) 686-7960
info@esc-toronto.com