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 1930 1931 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
*Nationality:
*Primary Language:
*Where did you hear about East Coast School of Languages?	Agent Canadian Education Centre Network Friend / Relative Internet Search Partner University or College Quality English Website Facebook Other
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 Program (UAP) - Full Time English for Business (EFB) - Full Time English for Business + Internship - Full Time English for Communicative Purposes (ECP) - Full Time Academic TOEFL - Full Time 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:	June 28th 2010* July 26th 2010 August 23rd 2010 September 20th 2010* October 18th 2010 November 15th 2010 3rd January 2011* 31-Jan-11 28th February 2011 4th April 2011* 2nd May 2011 30th May 2011 27 June 2011* 25th July 2011 22nd August 2011 19th September 2011* 17th Oct 2011 14th November 2011 Other Please note: the UAP program starts only on dates marked with an asterisk *
If you selected Other please specify:
University Achievement Program Only
*Do you plan to attend a Nova Scotia University or College?	Yes No
*Your chosen university or college: CompuCollege (The Eastern College) Dalhousie University (DAL) 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) 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:
Payment Information
*I want to make payment by the following method:
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)
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