Online Registration

ECSL has minimum space available in our school for minor students under 19 years of age.

Please complete the application form and we will assess your request once it is received.

If you are an Education Agent completing this form, please note that we must have a signed Agency Agreement in place before we can accept your student.

By completing this form, you agree to our policies and registration conditions.

Personal Information
Title (e.g. Mr., Mrs.):
*First Name:
*Family Name:
*Gender:	Male Female
*Birth Date:	day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
*Nationality:
*Primary Language:
*Where did you hear about East Coast School of Languages?	Agent OCSC Exhibition Descubra Fair Venezuela BMI’s Salvador Fair Friend / Relative Internet Search Partner University or College Quality English Website Facebook Tia Sawyer Lucy Jung Other (box below to let us know where)
If you selected Other please specify:
If you selected Agent please complete the following questions:
Agent Company Name:
Name of Agent:
Address
*Street and Street Number:
*City:
*Postal Code:
*Country:
Contact Details
*Telephone Number:
*Student Email Address:
Agent Email Address:
Fax:
Emergency Contact in Canada
Contact Name:
Relationship:
Telephone Number:
Program Information
*I would like to register for the following program:	University Achievement Pathway (UAP) English for Communication (EC) International Business English (IBE) TOEFL Homestay Only Other
If you selected Other please specify:
*I would like to register the following number of weeks:	4 8 12 16 20 24 30 36 40 44 48 52 Other
If you selected Other please specify:
*I would like to start on:	January 2nd 2012* January 9th 2012 January 16th 2012 January 23rd 2012 January 30th 2012 February 13th 2012 February 20th 2012 February 27th 2012 March 5th 2012 March 12th 2012 April 2nd 2012* April 9th 2012 April 16th 2012 April 23rd 2012 April 30th 2012 May 14th 2012 May 21st 2012 May 28th 2012 June 4th 2012 June 11th 2012 June 25th 2012* July 2nd 2012 July 9th 2012 July 16th 2012 July 23rd 2012 August 6th 2012 August 13th 2012 August 20th 2012 August 27th 2012 September 3rd 2012 September 10th 2012 September 24th 2012* October 1st 2012 October 8th 2012 October 15th 2012 October 22nd 2012 November 5th 2012 November 12th 2012 November 19th 2012 November 26th 2012 December 3rd 2012 December 10th 2012 Other *Please note: ECSL Recommended UAP Start Date marked with asterix *
If you selected Other please specify:
University Achievement Pathway Only
*Do you plan to attend a Nova Scotia University or College?	Yes No
*Your chosen university or college: Acadia University Cape Breton University Dalhousie University (DAL) Eastern College Mount Saint Vincent University (MSVU) Nova Scotia Agricultural College (NSAC) Nova Scotia College of Art & Design (NSCAD) Nova Scotia Community College (NSCC) Saint Francis Xavier University (St. FX) Saint Mary's University (SMU) University of King's College (King's) University of Prince Edward Island University of Regina Other If you selected Other please specify: *Have you already applied to university or college? Yes No If yes, have you received? Conditional Acceptance: Yes No Unconditional Acceptance: Yes No If yes, what is your student #: Exam: (i.e. TOEFL / IELTS etc.) Exam Score:
Homestay Information
*Are you under 19 years of age?	Yes No
If you are under 19 years of age you must stay with an ECSL Host Family.
*Do you wish to stay with an ECSL Host Family? Yes No
I can live with a smoker: Yes No I can live with children: Yes No I can live with cats: Yes No I can live with dogs: Yes No I am a smoker: Yes No I require car parking in Halifax: Yes No I have diet restrictions: Yes No I have allergies: Yes No I take medication for a medical condition: Yes No There are certain foods I cannot eat: Yes No Specify: If you answered yes to any of these questions about your health please provide information: Tell us about your hobbies and interests here: Do you require airport pickup in Halifax? Yes No Please provide flight information (if you have this confirmed): Flight information is required at least 2 weeks before arriving to guarantee airport pick-up. Arrival Date: Arrival Time: Airline and Flight Number: Arriving From:
Accommodation Options
*Would you like our Accommodation Coordinator to help you find other accommodation in Halifax?
	Yes No
Accomodation Options: International Hostel: Yes No YMCA: Yes No International Student Co-Ed Residence: Yes No Furnished Suites: Yes No Unfurnished Apartment: Yes No Bed and Breakfast: Yes No
Payment Information
*I want to make payment of  the $150 Application Fee by:
*I want to pay school tuition  fees by:
Health insurance is mandatory and will be added to your invoice if you cannot provide the following information.
*I have already purchased health insurance	Yes No
Health Insurance Company:
Policy Number:
Policy start date:
Policy end date:
Conditions and Verification
*By checking this box you agree to East Coast School of Languages terms and conditions:	I Agree (Click Here to View)
*Anti-Spam Security: Please enter the code displayed in the image in the box provided

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