Summer English Language & Cultural Experience
Student Registration Form

STUDENT INFORMATION
LAST NAME:
FIRST NAME:
MIDDLE NAME:
ADDRESS:
APT./UNIT No.:
CITY:
PROVINCE:
COUNTRY:
POSTAL CODE:
RESIDENT TELEPHONE:
BUSINESS TELEPHONE:
CELL:
EMAIL:
VERIFY EMAIL:
 
DATE OF BIRTH (DD MMM YYYY):
FIRST LANGUAGE SPOKEN:
LEVEL OF SPOKEN ENGLISH:
HIGHEST EDUCATION LEVEL:
AGENT CODE:
 

ALTERNATE CONTACT 1
LAST NAME:
FIRST NAME:
ADDRESS:
APT./UNIT No.:
CITY:
PROVINCE:
COUNTRY:
POSTAL CODE:
RESIDENT TELEPHONE:
BUSINESS TELEPHONE:
CELL:
EMAIL:
VERIFY EMAIL:
RELATIONSHIP to STUDENT:

ALTERNATE CONTACT 2
LAST NAME:
FIRST NAME:
ADDRESS:
APT./UNIT No.:
CITY:
PROVINCE:
COUNTRY:
POSTAL CODE:
RESIDENT TELEPHONE:
BUSINESS TELEPHONE:
CELL:
EMAIL:
VERIFY EMAIL:
RELATIONSHIP to STUDENT:

ADMISSION INFORMATION
Level: indicate placement requirement


FIELD TRIPS

CONDITIONS OF ATTENDANCE
All International visa students must comply with COSTI's Student Code of Behavior. Student's failure to follow school conduct or to comply with the conditions stated herewith may result in the student being expelled with no refund of tuition fee.

I/WE HAVE READ AND FULLY UNDERSTAND

I have read the statement and agree:

CONSENT FOR DISCLOSURE OF PERSONAL INFORMATION

I have read the statement and agree:



Course Number:
Dates:

Registration Fee (nonrefundable): $0 CAD
Course Fee: $0 CAD

Total Fee: $0 CAD

Solution Graphics