BODWELL LANGUAGE SCHOOL - REGISTRATION FORM
Personal Information
* Last name (Family Name)

* First name

Other name / English name

* Date of Birth (MM/DD/YYYY)
/ /
* Sex
Male   Female
* Nationality
 Address Emergency Contact
* Street

* City

  State / Prov

* Postal Code

* Country
 Name

Relation

Phone

Fax

E-mail
Native Language

* E-mail

* Phone

Fax
 * Do you want to purchase medical insurance from Bodwell?
Yes   No     (Some form of medical insurance is mandatory)
Start date of the insurance

(minimum 30 days)
days
How do you rate your English ability?   Beginner Low Intermediate High Intermediate Advanced
Study Option 1
START DATE: for  weeks
PROGRAMS
SUPER INTENSIVE - 30 hours per week (9:00—4:15)
INTENSIVE PLUS - 27 hours per week (9:00—3:00 Plus 3:15—4:15)
INTENSIVE - 25 hours per week (9:00—3:00)
SEMI-INTENSIVE MORNING PART-TIME - 15 hours per week (9:00—12:00)
SEMI-INTENSIVE AFTERNOON PART-TIME - 15 hours per week (1:00—4:15)
UNIVERSITY PREPARATION PROGRAM - 30 hours per week (9:00—4:15)
Study Option 2
START DATE: for  weeks
PROGRAMS
SUPER INTENSIVE - 30 hours per week (9:00—4:15)
INTENSIVE PLUS - 27 hours per week (9:00—3:00 Plus 3:15—4:15)
INTENSIVE - 25 hours per week (9:00—3:00)
SEMI-INTENSIVE MORNING PART-TIME - 15 hours per week (9:00—12:00)
SEMI-INTENSIVE AFTERNOON PART-TIME - 15 hours per week (1:00—4:15)
UNIVERSITY PREPARATION PROGRAM - 30 hours per week (9:00—4:15)
Desired Program: 
Homestay Application
Do you need Homestay?  Yes   No    If yes, please fill in the information below:
How long for Homestay? (minimum 4 weeks) * weeks and days
Do you smoke? 
Yes   No		 List foods you do not like to eat
Can you live with other smokers? 
Yes   No 		List foods you cannot eat
Medical condition
and special requests
Would you like to live in a homestay that has:
 
Yes
OK
No
 (If no, list reasons why)
dog
cat
young children
teenagers
another student
more than 2 other students
Airport Pick-up
* Yes   No
Arrival Date
Arrival Time
Airline & Flight Number
Airport Drop-off
* Yes   No
Departure date and flight information

** NOTE:  If this information is not yet available, please inform us once it is confirmed. To arrange pick up, please inform us a minimum of one week prior to your program start date.
Please Read and Agree to the Below
* How did you hear about Bodwell Language School?
Friend
Agent
Education Fair
Website
Advertisement
Embasssy
Other 		If you are registering through a Bodwell representative:
Representative Name

Telephone

Fax

E-mail
If you require assistance, please click here to contact the Admissions Department.