Contact Information:

• Last Name:     First Name:     Title: Mr. Mrs. Ms. Dr.
  
  
• Complete Mailing Address(street, suite, city & postal code):
  
  
• Home Tel:    Bus. Tel:    Email:

About going to France:

• Occupational Background: (knowing this enables us to better customize the activities during immersion):   Government Corporate Teacher Student Other
• Is this your first visit to France?   Yes     No
• Which level of French do you believe best describes you?    1. difficulty speaking in a simple conversation 2. comfortable speaking in a simple conversation 3. difficulty speaking in a complex conversation 4. comfortable speaking in a complex conversation
• Do you hold a Canadian Passport?    Yes   No       ** If you do not, please visit: http://france.visahq.ca/
• What is your preferred length of stay in France?   1 week     2 weeks     4 weeks

About you:

• Please list any allergies(** Note there is a pet cat in residence at the accommodations):
• Please list any dietary restrictions or food dislikes to ensure we may make accommodations: (** Note ** Vegan diet is not accommodated at this time):
• Please list some of your hobbies & interests:
• Please inform us of any medical conditions:

Health information:

• Contact person in case of emergency: (include full name, address, telephone number(s) and email):
• Relation to you:

Securing Your Space:

• COST: (select your term of stay - includes Tuition & Accommodation):   $2,000.00 - 1 week $3,800.00 - 2 weeks $7,000.00 - 4 weeks
• I am paying now by Paypal to secure my space   Yes
• I am paying now by Email Transfer to secure my space   Yes
• I am Mailing my payment to you    Yes

I understand there are limited spaces and my space is not secured until full payment is received Yes

Other Questions/Comments: 

** Note: There is a non-refundable charge of 10% for administration charges for any cancellations less than two weeks (14 calendar days) from the class start date. There will be no refund after the start date.

** The PAYPAL button will open your payment screen in a separate window. Once you have confirmed your payment, please DO NOT FORGET to return to this screen and press "Send Now" to complete your registration.

    

*** If you are having trouble sending, please a) reset your privacy settings and/or b) opening this webpage in a different browser - ie: firefox or explorer.
**** If this still fails, as a last resort only, fill in the information on the form directly in the browser, print (control 'p') and fax to us at 1-519-763-2239