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Application Form Promotion Code:

Student Information

Family Name: First Name(s):
Gender:
  • Male
  • Female
    •
    Date of Birth (dd/mm/yyyy):
    Country of Birth: City of Birth:
    Mother Tongue: Nationality:
    Full Address:
    City: Postcode:
    Country:
    E-mail:
    Telephone:
    English Level:
    Type of Visa: Passport No:

    About your legal guardian

    Fill out this section if student is under 18 years of age. (In Vancouver this applies to students under 19 years of age)

    Family Name: First Name(s):
    Home telephone number: Email address:
    Permanent address:

    School & Course Information

    School Location:
    Course Name:
    Number of Weeks: Start Date:

    If more schools are booked

    School Location 2:
    Course Name:
    Number of Weeks: Start Date:

    Accommodation

    Accommodation Type:
  • Homestay
  • Residence
  • Apartment
  • Hotel
    •
    Room Type
  • Single
  • Twin
  • Multi
    •
    Check-in (dd/mm/yyyy) Check-out (dd/mm/yyyy)
    Accommodation Name (if several options are advertised):
    Any special requests? (e.g. medical requirements, allergies, special diet, no pets)
  • Yes
  • No
    • If yes, please specify:
    Do you smoke?
  • Yes
  • No
    •
    Homestay supplements (only where advertised - charges apply)
  • Private bathroom
  • Close to school supplement
  • Homestay special diet
  • Luggage retainer
    • Zone (London/Dublin):
    Accommodation Option 2 (if first choice is not available)

    Other accommodation supplements may apply, including seasonal supplements during the summer or at Christmas. See price list or speak to a Kaplan representative for details.

    Kaplan Representative Information

    Partner Name/Contact Person:
    Country:
    E-mail:
    Telephone: Fax:
    For all partner bookings, please confirm who will be responsible for the total payment of this booking by selecting an option below
  • Partner
  • Student
  • Partner and Student (Provide details including amounts):
    •
    Partner Signature:

    Medical Conditions

    Do you have a disability, impairment, or long-term medical condition which may affect your studies?
  • Yes
  • No
    •

    If yes, please provide medical documentation from a relevant treating professional detailing the impact of your condition on your ability to meet academic demands. Please see our Terms and Conditions (Application Process / 6. Health Declaration)

    Additional Services (Charges apply)

    Would you like Kaplan Travel and Medical Insurance?
  • Yes
  • No
    • (If not, you will need to organise your own medical insurance)
    If you are travelling to Australia, would you like Overseas Student Health Cover?
  • Yes
  • No
    • (Mandatory for student visa)
    Would you like an airport transfer?
    (Please send flight details to your Kaplan representative)     		On arrival?
  • Yes
  • No

    • On departure?
  • Yes
  • No
    •
    I would also like to book the following services
  • Internship Placement (Available in London, Dublin, and Auckland)

  • University Placement Service

  • Courier service for visa documentation
    •

    Payment

    At this time, I wish to pay:
  • The application fee
  • The full fees
    •
    Payment method:
  • Credit card (Please contact us to arrange payment or visit www.kaplaninternational.com to pay online)

  • Bank transfer (We will send you transfer details)
    •
    I am sponsored by:

    Declaration

    I confirm that I have read, understood, and agreed to be bound by Kaplan’s Terms and Conditions detailed on pages 43-48 and Kaplan’s privacy policy which can be found at www.kaplaninternational.com/privacy.
    I authorise any licensed hospital or physician to initiate medical treatment for myself in case of medical emergency or for my child if he/she is under 18 years of age.*
    Signature Date:
    Signature of parent/guardian
    (required if student is under 18 years old)*     		Date:

    Please return the completed form to the Kaplan International Languages booking office or to your local representative.