Tuition Hawaii English
Registration Form

ENROLL FOR CLASS HERE.

PART 1 - Personal Information
First & Last Name
Age Male Female
Nationality
City of Birth
Passport Number

PART 2 - Address and Contact Information
Address
Email
Telephone

PART 3 - EMERGENCY Contact Information
First & Last Name
Relationship (Parent, Friend, Sponsor)
Address
Email
Telephone

PART 4 - English Program
Which program are you registering for?
Starting Date
English Level
Which skill do you want to study and improve the most? Speaking & Pronunciation
Grammar & Writing
Reading & Vocabulary
General English - All Skills
Will you be studying English to prepare for an exam?
Yes No
If yes, which exam? CAMBRIDGE
TOEFL
TOEIC
Other
Comments and Questions About English Programs

PART 5 - Accommodations and Airport Transfer
Do you need Airport pick-up & transfer to accommodations?
Yes No
Do you want us to find you Accommodations?Yes No
Accommodations
Start Date   (mm/dd/2008)
Number of Weeks
Do you smoke?Yes No
Which kind of accommodation
do you want?		 Private Apartment-condo
Share Apartment-condo
Homestay - Live With Host Family
Residence Hall

PART 6 - Payment Information
I would like to pay by:
Type of Credit Card Visa  MC  Amex  JCB  Discover
Card Holder Name  
Card Number  
3-digit Verification Code on back of card
Expiration Date //
Promotion Number (optional)

PART 7 - Legal and Medical Information
I will purchase medical insurance prior to starting Hawaii Palms English Program to cover all medical expenses during my stay in Hawaii.   Yes
I will abide by the school rules and policies of Hawaii Palms English School.   Yes
I understand that my registration fee of $100 is not refundable should I decide to cancel my enrollment at Hawaii Palms English School.   Yes
I understand that when Hawaii Palms English School receives this registration form, I will receive confirmation by email and an invoice for my tuition, registration fee, and other fees.   Yes