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

  • The above conditions relating to COSTI Refund Policy, Conditions of Attendance
  • The applicant is 18 years or older on the course start date
  • Certify that the information contained herein is valid and true
  • COSTI shall not be held liable for losses or expences as a result of COSTI being unable to provide education owing to labour disputes or other causes beyond its control.

I have read the statement and agree:

CONSENT FOR DISCLOSURE OF PERSONAL INFORMATION

COSTI recognizes that information provided in the Client Registration Form is confidential and will not be released without my prior consent. I hereby give consent to COSTI to share the information I have provided herein to staff within COSTI for the sole purpose of providing services to me. I understand that COSTI will use aggregate statistical data from the Client Registration System for planning and presentation purposes.

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