English Summer Camp Registration Form

All field marked with "*" are required

Courses:

	Toronto		Vancouver
Platinum Package with Homestay	3 Weeks - $2,850	4 Weeks - $3,550	3 Weeks - $2,850	4 Weeks - $3,550
Platinum Package with Residence	3 Weeks - $4,200	4 Weeks - $4,950

Gold Package with Homestay	3 Weeks - $2,600	4 Weeks - $3,200	3 Weeks - $2,600	4 Weeks - $3,200
Gold Package with Residence	3 Weeks - $3,950	4 Weeks - $4,650

Tennis Package with Homestay	3 Weeks - $3,600	4 Weeks - $4,550
Tennis Package with Residence	3 Weeks - $4,900	4 Weeks - $5,950

Please select your course

* Course Start Date: Please select your start date

* Nationality: Please enter your nationality

* Passport #: Please enter your passport number

* Last Name: Please enter your last name

* First Name: Please enter your first name

* Date of Birth: (mm/dd/yyyy) Please enter your date of birth

* Home address: Please enter your home address

* City: Please enter your city

* Country: Please enter your country

* E-mail: Please enter a valid email address

* Phone: Please enter your phone number

Agency:

Contact person:

Email:

Arrival date: (mm/dd/yyyy) Please enter your arrival date

Departure date: (mm/dd/yyyy) Please enter your departure date

Please note: It is mandatory for ILAC students to have Medical Insurance during their stay in Canada

* Do you have Medical Insurance: Yes No Please select if you have medical insurance

Policy number: Please enter your policy number

Start Date: (mm/dd/yyyy) Please enter the start date of your insurance policy

End Date: (mm/dd/yyyy) Please enter the end date of your insurance policy

Will you buy it at ILAC?: Yes No Please select if you will buy your insurance at ILAC

* Do you have any Allergies Yes No Please select if you have any allergies

Please list them Please list your allergies

* Do you have any Medical Problems Yes No Please select if you have any medical problems

Please list them Please list your medical problems

* Do you have any Food Restrictions Yes No Please select if you have any food restrictions

* Please list them Please list your food restrictions

* Do you Smoke Yes No Please select if you smoke