Summer Academy Italy - Online Application Form

COURSE CHOICES

Please choose your preferred course First Choice:

Course:
Code:

If first choice is not available Second Choice:

Course:
Code:

Previous Knowledge of Italian:

No previous knowledge of Italian:

STUDENT INFORMATION

Family Name:

Given Name(s):

Permanent Address:
(include postal/zip)

Email Address:

Home Telephone:

Date of Birth:

Day:

Month:

Year:

MOTHER'S INFORMATION

Mother's Name: (Mrs/Ms/Dr)

Home Address
(include postal/zip):

Email Address:

Home Telephone:

Business Telephone:

FATHER'S INFORMATION (if different from above)

Father's Name: (Mr/Dr)

Home Address:
(if different from above)

Email Address:

Home Telephone:

Business Telephone:

GUARDIAN'S INFORMATION (if necessary)

Name of Legal Guardian (if applicable):
(Mr/Mrs/Ms/Dr)

Guardian's Address:
(include postal/zip)

Email Address:

Home Telephone:

Business Telephone:

SUMMER CONTACT INFORMATION

Name of Summer Contact

Home Telephone:

Business Telephone:

Email Address:

EMERGENCY CONTACT INFORMATION

In case of emergency, please contact:

Home Telephone:

Business Telephone:

PAYMENT, REPORTS & SCHOOLING

Invoices for fees and other charges should be sent to:

Mother Father Guardian

Reports & other information should be sent to:

Mother Father Guardian

Name & Address of
Present School:

School Phone Number:

School Fax Number:

Guidance Counselor:

STUDENT PREFERENCES QUESTIONNAIRE

Please write a 250 word essay explaining why you wish to attend our summer program. (to be completed by applicant)
Briefly describe your ideal roommate or provide us with the name of an attending student you wish to room with
Do you have any physical conditions that we should be aware of? (e.g. Food allergies, epilepsy, diabetes)
Do you have any restrictions with regard to physical activity?

INSURANCE

I wish to purchase:
Cancellation Insurance add $120.00
Medical Insurance add $60.00 (available to Canadian residents only)

Please provide us with an email address where we can contact you: