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CanadaWide English Network
Registration Form
* required
*First
Name		 Last
Name
Gender male female Date of Birth
Mailing
Address		 * * 
* Country Nationality
Tel FAX
* E-mail First Language

Please select your school and program dates
(please press ctrl and click the mouse to select multiple dates)
* Please note that CanadaWide will confirm the start date.
* Choose Your School

Number of Weeks

 First Week
School:
YOU RECEIVE A FREE RETURN FLIGHT BETWEEN CANADAWIDE SCHOOLS
WHEN STUDYING A MINIMUM OF 12 WEEKS AT EACH.

Medical insurance
@ $20 per week

Please provide me with medical insurance for the entire length of my program.

I will provide my own medical insurance.
Please provide me with weeks of insurance starting
Have you studied English before? Yes No If yes, for how many years?
Have you written any of the following Tests?
TOEIC Yes No Test Score
TOEFL Yes No Test Score
Other Test Name Test Score
How do you rate your English?
Speaking Poor Fair Good
Listening Poor Fair Good
Reading Poor Fair Good
Writing Poor Fair Good
Homestay Placement Information
Have you travelled overseas before? Yes No
If yes, where have you lived?
Have you stayed with a host family before? Yes No
If yes, where?
What are your homestay preferences? Family with teenagers (older than 12)
Family with young children (12 or younger)
Adults with no children
Any of the above
Do you smoke? Heavy Smoker Light Smoker No
Do you drink alcohol? Yes Sometimes No
Do you have any allergies? Yes No
If yes, please explain
Is there any kind of pet that you cannot live with?.
Do you have any illnesses that we should know about?
Do you take any medication?
What is the highest level of education you have completed?
What was your major?
What are your interests and hobbies?
What is your occupation?


Please write a few lines talking about what you expect to get out of studying in Canada.

Statement of Registration

I have read and understood the CanadaWide English Network refund policy.

I realize that a $200 deposit must be received before a Letter of Acceptance will be sent. I realize that the deposit amount will be deducted from my program fees. I understand that the deposit is non-refundable.
I will pay my deposit with the Credit Card Information below. You may bill my card.
I will pay my deposit cheque or wire transfer.

I realize that the tuition fees must be received no later than 30 days before the program start date or my seat may be cancelled and my deposit forfeited. I realize that the program fees are non-refundable except in the situation of a visa refusal (The original written refusal from Canadian Immigration and the original Letter of Acceptance must be received by CanadaWide).
I will pay my program fees with the Credit Card Information below. You may bill my card.
(The charge will occur no earlier than 30 days before the program starts.
I will pay my program fees by cheque or wire transfer.

I have read and understand the registration information. I would like register in the programs and accommodations which I have selected along with the appropriate fees and agree to pay all of the fees associated with the programs I have selected.

I will send my payment by: online fax mail Bank Transfer
Online Payment: Visa Master Card JCB
My Credit Card Number is
Expiry Date
Card Holder Name
Registrant's Full Name
Promotional Code or Agent ID

If you have any questions or comments please make them here.

CanadaWide English Network
PO Box 78571, Wilderton Station
Montreal, Quebec H3S 2W9
Tel: (514) 346-5145 Fax: (902) 628-1190
Email: registrar@canadawide-english.com
Website: www.canadawide-english.com