Summer Teen JAPAN 2014-Registration-blank

SUMMER REGISTRATION FORM
2014
Student Information
Mr.
(男性)
Ms.
Nationality: _________________________________________ Mother Tongue: ___________________________________ Passport#: ________________________________________________
(母国語)
(パスポート番号)
(国籍)
Last Name: ___________________________________________________ First Name: __________________________________________________________________
Date of Birth: ____________________________
YYYY / MM / DD
School Campus
(名)
(生年月日)
(姓)
Home Address: ________________________________________________________________ City: _____________________________________ Province: : _______________________________________________________
Toronto
(市)
(都道府県)
(住所)
トロント校
Country: _________________________________________________ Email: __________________________________________________________ Telephone: ______________________________________________________
(メールアドレス)
(電話番号)
(国)
Vancouver
Agent Information
バンクーバー校
Agency: _________________________________________________ Contact Person: ______________________________________________________ Email: ____________________________________________________
(担当者名)
(メールアドレス)
(エージェント名)
(女性)
Arrival Date / Flight Information: ___________________ / ___________________________________ Departure Date / Flight Information: ___________________ / ___________________________________
YYYY / MM / DD
YYYY / MM / DD
(出発日/ フライト情報)
(到着日/ フライト情報)
Choose Your Program
Summer English Camps
Start Date: ________________
YYYY / MM / DD
(入校日):
Package
Platinum
プラチナ
Accommodation
Homestay
ホームステイ
Platinum
プラチナ
Residence (Toronto only)
レジデンス（トロントのみ）
Teenager English Program
Tuition (20 lessons/week)
授業料 (週20レッスン)
Tuition (25 lessons/week)
授業料 (週25レッスン)
Registration
入学金
Single homestay
All fees are in Canadian dolars
表示金額は全てカナダドルです。
$
# of weeks
$
# of weeks
All fees are in Canadian dolars 表示金額は全てカナダドルです。
Parents/Guardians Information*
Parent/Guardian 1 (保護者1)
$
# of weeks
Full Name (氏名)
Twin Homestay
$
# of weeks
Date of birth
(dd/mm/yyyy)
Homestay placement
$
シングルルームホームステイ
ツインルームホームステイ
宿泊手配料
Return Airport
Transfer
$
Health Insurance
$
Custodianship Letter
$
Residence
$
Total
$
後見人申請書
レジデンス（トロントのみ） 3 weeks
2 weeks
(if appicable)
(Preferably from both parents/guardians)
Parent/Guardian 2 (保護者2)
(生年月日)
Home Address
& Telephone
(住所ならびに電話番号)
空港出迎え＆見送りサービス
医療保険
4 weeks
保護者情報 (後見人申請書の手配が必要な場合のみ記入要)
$
Start Date: ________________
YYYY / MM / DD
(入校日):
# of weeks
Letter (if applicable) $100
Extra Fees•• Custodian
Courier Fee (if applicable) $50
• Residence Security Deposit $250
(refunded after check-out if no damages occur)
別料金(該当する場合のみ): 後見人手配書$100 / 後見人手配書の郵送費$50 / レジデンス･セキュリティーデポジット$250
*Textbooks not included **Includes Unaccompanied Minor Service (UMS) ***2.50 daily **** Please request a quote to [email protected]
*テキスト代は含まれません。**UMS代が含まれます。手配をご希望の方はお申し付けください。***$2.50/日
Medical Information Please note – it is mandatory for ILAC students to have Medical Insurance during their stay in Canada (注: ILACでの就学中は保険加入が必須です。)
Do you have Medical Insurance?
YES
NO
Policy No.: ___________________________________________________________________________________________________
(保険の有無)
(無)
(有)
(保険番号)
If NO, will you buy it from ILAC?
YES
NO
(要)
(不要)
(ILACでの保険手配)
List Allergies: _________________________________________________________________________________________________
Do you have any allergies?
YES
NO
(詳細)
(有)
(無)
(アレルギーの有無)
Do you have any medical problems?
YES
NO
List Medical Issues: __________________________________________________________________________________________
(有)
(無)
(疾患の有無)
(詳細)
Do you have any food restrictions?
YES
NO
List Food Restrictions: _______________________________________________________________________________________
(有)
(無)
(食事制限の有無)
(詳細)
Withdrawals, Transfers and Refunds プログラムの取り消し、変更および返金について：ハンドブックP12 (3.10) をご参照ください。
IF YOU ARE DENIED A VISA
You are entitled to receive a FULL REFUND (less program registration fee and all bank transfer charges) if you are unable to obtain lawful entry to Canada for the purpose of studying at ILAC.
You must provide the letter from the Canadian Embassy stating that your Visa to enter Canada was denied. Students who have applied through an agent must contact the agent for a refund.
ONCE YOU RECEIVE AN ENTRY VISA OR IF AN ENTRY VISA IS NOT REQUIRED
Students who have obtained their visa with the help of a letter of acceptance from ILAC and a conditional letter of acceptance and/or supporting letter to a Pathway Program institution will be expected to complete their English language training at ILAC and not be
eligible for a refund. Once you have started studying, the first 4 weeks of your tuition and homestay are non-refundable. Refunds are calculated based on the unused portion of your tuition (regular brochure prices will be charged for the used portion) according to the
refund policy below. For the accommodation portion, ILAC requires at minimum, a 2-week written notice for any changes, cancellations, or postponements. Otherwise a 2 week accommodation fee will be applicable and the homestay placement fee is not refundable.
To withdraw from a program at ILAC, you must first provide a written letter outlining the reason for withdrawing. If you chose to withdraw from ILAC, you must demonstrate that your stay in Canada is lawful or that you will be leaving the country. ILAC will require
proof that your Visa status is lawful. ILAC may require proof that you are leaving the country early by showing a photocopied plane ticket. If you are attending another school you will need to provide evidence that you meet the visa requirement; you will have to
re-apply for a new Visa. Students who have applied through an agent must contact the agent for a refund. ILAC may be required to submit attendance and/or advancement data for all international students to the federal government. Poor attendance, lack of
progression and unlawful stays in the country may result in visa removals and a student may be asked to return to their home country.
Refund Policy – Language Programs
From 2 weeks prior to start date up to 10% of course completed ................60% refund | Up to 30% of course completed.................................................................................40% refund | After 30% of course completed....................................................................................NO refund
Agreement and Medical Authorization 医療保険の加入について：ハンドブックP8 (3.4) をご参照ください。
ILAC students must understand that medical insurance is mandatory while attending ILAC. ILAC has offered to each student the option to purchase medical insurance during the registration/application process.
If a student declined to purchase ILAC's medical insurance they are required to purchase their own insurance from a different provider. The student must provide evidence of medical insurance.
Student disclaimer: 生徒の免責事項について：ハンドブックP8 (3.4) をご参照ください。
I do waive and release all claims against ILAC for any injury, loss, damage, accident, delay and expenses from my participation in the program.
I release and agree to indemnify ILAC with regard to any financial obligations or liabilities that I may personally incur or any damage or injury to the person or property of others that I may cause while participating in the program. I also understand that ILAC is not
responsible for any injury or loss suffered or caused by me while away from the school for any reason.
If I become ill, injured or incapacitated, ILAC, the host family, or the local coordinator may take such actions as any of them considers necessary, including medical treatment for me and transporting me back to my country, at my own expense. I understand that my
participation at ILAC and in the accommodation program may be terminated at the sole discretion of ILAC without a refund of fees and that I may be sent home at my expense if I do not adhere to these rules, standards and instructions.
I agree that Canadian law shall apply to this agreement and I agree to submit to the jurisdiction of Canadian law. I agree to pay promptly all telephone bills charged by me to the host family phone in case I did not use a pre-paid phone card.
I have read and agree to the Policies and Procedures as outlined in the Student Handbook and understand my Student Rights and Responsibilities while attending at ILAC. I understand that any false or incomplete information submitted in support of my registration
may invalidate my registration. If the applicant is less than 18 years old, please have a parent co-sign below. To review the current student handbook visit www.ilac.com.
Applicant signature:
（出願者署名）
Parent Signature:
（保護者署名）
Date:
( 日付)
YYYY /
MM / DD
I, hereby certify that the above information is true and complete. I have read and understand all of ILAC policies, including Code of Conduct. I understand that any false or incomplete information
submitted in support of my registration may invalidate my registration. I agree to speak only English on School property.
プログラム申込書の記載内容が事実と相違ないことを認め、ILAC Student HandbookならびにCode of Conductを読み規定を理解した上で、生徒としての権利と義務を守りクラスを受講します。
記載内容が事実と相違することが判明した場合、除籍となる可能性があることを理解します。また、ILACの英語オンリーの方針に従うことに同意します。

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