Sei sulla pagina 1di 2
FLS International English Language Programs 2014 Specialty Tour Application For offi ce use only App.

FLS International

English Language Programs

2014

Specialty Tour Application

For offi ce use only App. #: Date Received: / /

For office use only

App. #:

Date Received:

/

/

Student Information

1
1

Name

5
5

Country of Citizenship

 
 

Family Name(s)

 

First Name

Middle Name

 
2
2

Student

 
6
6

Country of Birth

Permanent

Street Address

 

Home

7
7

Where did you obtain this application?

 

Address

City

State/Department/Province

Postal Code

 

Country

Telephone

Fax

 
8
8

Do you require an I-20 form?

  8 Do you require an I-20 form? Yes No

Yes

  8 Do you require an I-20 form? Yes No

No

 

E-mail

 
3
3

Gender

Male

Male

3 Gender Male Female 4 Date of Birth

Female

4
4

Date of Birth

3 Gender Male Female 4 Date of Birth

Program Selection

Month

Day

Year

9
9

Please check the start date of the program you wish to attend

Discover California

at

Citrus College

January 5, 2014you wish to attend Discover California at Citrus College January 26, 2014 March 9, 2014 March

January 26, 2014Discover California at Citrus College January 5, 2014 March 9, 2014 March 23, 2014 June 22,

March 9, 2014at Citrus College January 5, 2014 January 26, 2014 March 23, 2014 June 22, 2014 June

March 23, 2014College January 5, 2014 January 26, 2014 March 9, 2014 June 22, 2014 June 29, 2014

June 22, 20145, 2014 January 26, 2014 March 9, 2014 March 23, 2014 June 29, 2014 July 6,

June 29, 2014January 26, 2014 March 9, 2014 March 23, 2014 June 22, 2014 July 6, 2014 July

July 6, 2014March 9, 2014 March 23, 2014 June 22, 2014 June 29, 2014 July 13, 2014 July

July 13, 20142014 March 23, 2014 June 22, 2014 June 29, 2014 July 6, 2014 July 20, 2014

July 20, 20142014 June 22, 2014 June 29, 2014 July 6, 2014 July 13, 2014 August 10, 2014

August 10, 20142014 June 29, 2014 July 6, 2014 July 13, 2014 July 20, 2014 December 14, 2014

December 14, 2014July 6, 2014 July 13, 2014 July 20, 2014 August 10, 2014 December 21, 2014 December

December 21, 201413, 2014 July 20, 2014 August 10, 2014 December 14, 2014 December 28, 2014 Cinema Camp

December 28, 201420, 2014 August 10, 2014 December 14, 2014 December 21, 2014 Cinema Camp at Saddleback C

Cinema Camp

at

Saddleback

College

June 22, 20142014 Cinema Camp at Saddleback C o l l e g e July 6, 2014 July

July 6, 2014Camp at Saddleback C o l l e g e June 22, 2014 July 13, 2014

July 13, 2014C o l l e g e June 22, 2014 July 6, 2014 Discover California Junior

Discover

California Junior

at

Sonrise Christian School

June 22, 2014Discover California Junior at Sonrise Christian School June 29, 2014 July 6, 2014 July 13, 2014

June 29, 2014Junior at Sonrise Christian School June 22, 2014 July 6, 2014 July 13, 2014 July 20,

July 6, 2014at Sonrise Christian School June 22, 2014 June 29, 2014 July 13, 2014 July 20, 2014

July 13, 2014Christian School June 22, 2014 June 29, 2014 July 6, 2014 July 20, 2014 July 27,

July 20, 2014June 22, 2014 June 29, 2014 July 6, 2014 July 13, 2014 July 27, 2014 August

July 27, 20142014 June 29, 2014 July 6, 2014 July 13, 2014 July 20, 2014 August 3, 2014

August 3, 20142014 July 6, 2014 July 13, 2014 July 20, 2014 July 27, 2014 Surf Camp at

Surf Camp

at

Saddleback College

June 29, 201427, 2014 August 3, 2014 Surf Camp at Saddleback College July 6, 2014 July 13, 2014

July 6, 20143, 2014 Surf Camp at Saddleback College June 29, 2014 July 13, 2014 July 20, 2014

July 13, 2014Camp at Saddleback College June 29, 2014 July 6, 2014 July 20, 2014 (2-week) Acting Camp

July 20, 2014 (2-week)Saddleback College June 29, 2014 July 6, 2014 July 13, 2014 Acting Camp at Saddleback College

Acting Camp

at

Saddleback College

June 22, 2014July 20, 2014 (2-week) Acting Camp at Saddleback College July 13, 2014 California Summer at Cal

July 13, 2014(2-week) Acting Camp at Saddleback College June 22, 2014 California Summer at Cal State, Northridge June

California Summer

at

Cal State, Northridge

June 29, 2014July 13, 2014 California Summer at Cal State, Northridge July 6, 2014 July 13, 2014 July

July 6, 2014California Summer at Cal State, Northridge June 29, 2014 July 13, 2014 July 20, 2014 Junior

July 13, 2014at Cal State, Northridge June 29, 2014 July 6, 2014 July 20, 2014 Junior Camp at

July 20, 2014State, Northridge June 29, 2014 July 6, 2014 July 13, 2014 Junior Camp at Cal State,

Junior Camp

at

Cal State, Northridge

June 29, 20142014 July 20, 2014 Junior Camp at Cal State, Northridge July 6, 2014 July 13, 2014

July 6, 20142014 Junior Camp at Cal State, Northridge June 29, 2014 July 13, 2014 July 20, 2014

July 13, 2014Camp at Cal State, Northridge June 29, 2014 July 6, 2014 July 20, 2014 Photography Camp

July 20, 2014State, Northridge June 29, 2014 July 6, 2014 July 13, 2014 Photography Camp at Las Vegas

Photography Camp

at

Las Vegas Institute

June 29, 2014July 20, 2014 Photography Camp at Las Vegas Institute July 13, 2014 Culinary Camp at Las

July 13, 2014Photography Camp at Las Vegas Institute June 29, 2014 Culinary Camp at Las Vegas Institute July

Culinary Camp

at

Las Vegas Institute

July 13, 20142014 July 13, 2014 Culinary Camp at Las Vegas Institute Extra Weeks of Study Basketball Camp

Extra Weeks of Study

Basketball Camp

at

Fisher College

June 29, 2014Extra Weeks of Study Basketball Camp at Fisher College July 13, 2014 Outdoor Adventure Camp at

July 13, 2014of Study Basketball Camp at Fisher College June 29, 2014 Outdoor Adventure Camp at Tennessee Tech

Outdoor

Adventure Camp

at

Tennessee Tech

June 29, 2014July 13, 2014 Outdoor Adventure Camp at Tennessee Tech July 13, 2014 Tennis Camp at Tennessee

July 13, 2014Outdoor Adventure Camp at Tennessee Tech June 29, 2014 Tennis Camp at Tennessee Tech June 29,

Tennis Camp

at

Tennessee Tech

June 29, 201429, 2014 July 13, 2014 Tennis Camp at Tennessee Tech July 13, 2014 Hip-Hop Dance Camp

July 13, 201413, 2014 Tennis Camp at Tennessee Tech June 29, 2014 Hip-Hop Dance Camp at Fisher College

Hip-Hop Dance Camp

at

Fisher College

June 29, 20142014 July 13, 2014 Hip-Hop Dance Camp at Fisher College July 13, 2014 Discover Boston at

July 13, 20142014 Hip-Hop Dance Camp at Fisher College June 29, 2014 Discover Boston at Boston Commons August

Discover Boston

at

Boston Commons

August 3, 201429, 2014 July 13, 2014 Discover Boston at Boston Commons December 14, 2014 December 21, 2014

December 14, 20142014 Discover Boston at Boston Commons August 3, 2014 December 21, 2014 University Tour East at

December 21, 2014at Boston Commons August 3, 2014 December 14, 2014 University Tour East at Boston Commons July

University Tour East

at

Boston Commons

July 13, 2014December 21, 2014 University Tour East at Boston Commons Boston Summer at Fisher College June 29,

Boston Summer

at

Fisher College

June 29, 2014Commons July 13, 2014 Boston Summer at Fisher College July 6, 2014 July 13, 2014 July

July 6, 201413, 2014 Boston Summer at Fisher College June 29, 2014 July 13, 2014 July 20, 2014

July 13, 2014Summer at Fisher College June 29, 2014 July 6, 2014 July 20, 2014 TOEFL/SAT Prep at

July 20, 2014Fisher College June 29, 2014 July 6, 2014 July 13, 2014 TOEFL/SAT Prep at Fisher College

TOEFL/SAT Prep

at

Fisher College

June 29, 201413, 2014 July 20, 2014 TOEFL/SAT Prep at Fisher College July 13, 2014 10 Extra Weeks:

July 13, 201420, 2014 TOEFL/SAT Prep at Fisher College June 29, 2014 10 Extra Weeks: students may add

10
10

Extra Weeks: students may add extra weeks of General English study for an additional $700 per week.

I would like W e e k s weeks of General English.

I would like

Weeks

weeks of General English.

Please indicate the revised start and end date of your program including your additional weeks of study. Students may start their program on any Monday and end on any Friday.

Program start date

Month Day Year
Month
Day
Year

Program end date

Month Day Year
Month
Day
Year
11
11

Extra Nights: $55 per night (homestay),

$75 per night (apartment, dormitory, International House)

Anticipated arrival date

Month Day Year
Month
Day
Year

Anticipated departure date

Month Day Year
Month
Day
Year

Continued on Reverse Side

FLS International English Language Programs 2014 Specialty Tour Application 12 Student Information Name FLS Center

FLS International

English Language Programs

2014

Specialty Tour Application

12
12

Student Information

Name

FLS Center

Family Name(s)

First Name

Middle Name

13
13

Health Insurance: mandatory for all students; you may purchase it in your home country. Health insurance is also available from FLS at

 

$35 per week. Would you like to purchase health insurance through FLS?

 

Yes$35 per week. Would you like to purchase health insurance through FLS?   No

No$35 per week. Would you like to purchase health insurance through FLS?   Yes

14
14

Would you like your I-20 Form and acceptance documents to be sent by Express Mail? Express mail delivery is available for an additional $55 fee. NNote:ote: fforor aapplicationspplications rreceivedeceived llessess tthanhan tthreehree weeksweeks priorprior ttoo tthehe sstartingtarting ddate,ate, tthehe ddocumentsocuments mmustust bbee sentsent byby ExpressExpress Mail.Mail.

 

Yesd date, ate, t the he d documents ocuments m must ust b be e sent

Nod date, ate, t the he d documents ocuments m must ust b be e sent

 
15
15

Would you like FLS to process the $200 SEVIS Application Fee for you?

Yes15 Would you like FLS to process the $200 SEVIS Application Fee for you? No

No15 Would you like FLS to process the $200 SEVIS Application Fee for you? Yes

NNote:ote: tthishis iiss oonlynly fforor sstudentstudents wwhoho nneedeed aa sstudenttudent FF-1-1 vvisaisa ffromrom tthehe UUSS EEmbassy.mbassy. IIff YYESES tthenhen aa vvalidalid ccreditredit ccardard mmustust bbee eenteredntered bbelelow.ow. ThisThis feefee willwill bebe chargedcharged byby thethe U.S.U.S. GovernmentGovernment notnot byby FLSFLS Interna-Interna-

16
16

Unaccompanied Minor: Upon request, FLS will provide the name and contact information of a specific designated driver to the agent and

airline for pick-up and provide chaperone service to airport security for airport drop-off. Cost is $100 round-trip. Would you like FLS to

provide Unaccompanied Minor Service?

NNote:ote: iiff yyouou rrequestequest tthehe UUnaccompaniednaccompanied MMinorinor ServiceService fromfrom youryour airline,airline, youyou mustmust alsoalso selectselect thisthis feefee forfor FLS’FLS’ service.service.

this fee fee for for FLS’ FLS’ service. service. Yes Payment Information No Please send the

Yes

Payment Information

FLS’ FLS’ service. service. Yes Payment Information No Please send the following fees with your application:

No

Please send the following fees with your application:

A. Application processing fee—required for all applications (non-refundable)

B. If SEVIS processing is requested, payment must be included with application: US $200 (non-refundable)

C. If express delivery is requested, payment must be included with application: US $55 (non-refundable)

D. If unaccompanied minor service is requested, payment must be included with application: US $100

US $ 150 US $

US $

US $

US $

18
18

Promotion Code

Please Indicate Total Enclosed
Please Indicate Total Enclosed

The charges listed above may be paid by travelers check, personal check, international money order, bank draft, or transfer on a USA bank. Please note that all charges must be paid in US dollars. These charges may also be paid by credit card. Only Visa, MasterCard, or American Express cards are accepted. Please do not send cash through the mail.

are accepted. Please do not send cash through the mail. American Express MasterCard Credit Card Number

American Express

Please do not send cash through the mail. American Express MasterCard Credit Card Number Visa Security

MasterCard

Credit Card Number

Visa Security Code
Visa
Security Code

Expiration Date

Signature

Please mail application, fees, and a financial statement to:

FLS International—Administrative Offices 301 N. Lake Ave., Suite 310 Pasadena, CA 91101, U.S.A. Tel: (626) 795-2912 | Fax: (626) 795-5564 | E-Mail: fls@fls.net

In case of emergency please contact:

Name

Telephone

E-mail Address

Fax

Parental authorization for minors:

I authorize FLS International and its agents to allow any necessary and appropriate emergency medical services for my child in case of

accident or illness and release them from all liability.

((MustMust bbee completedcompleted forfor allall studentsstudents underunder 1818 yearsyears ofof age)age)

Signature

Relationship to student (parent, guardian, etc.)

Family Visitation:

For minor students (under the age of 18) who intend to arrange a visit with relatives during their FLS program, the student’s parent or guard- ian must complete and sign a Family Visit Authorization Form. This form may be obtained upon request from any FLS staff member or agent.