Online Enrolment Form

On submission of this form, an email will be sent confirming
the details you have submitted. CLCA will contact you
to confirm placement.

All fields are compulsory unless indicated by *

Personal Details

All fields are compulsory unless indicated by *

Family Name

Given Name(s)

Gender

Male Female

Address

Country

ZIP Code*

Date of Birth

day		month		year
	/		/

E-mail

Telephone

Fax*

Nationality

Passport No.*

MEDICAL INSURANCE

Medical, travel and personal insurance is compulsory for all students.

If you do not have medical and travel insurance, you will have to pay for any treatment needed during your stay in New Zealand. It is required that you have medical and travel insurance before coming to CLCA. If you do not have medical and travel insurance, we will arrange it for you.

Do you have medical insurance?

Yes, I have already have insurance
No I don't. Please arrange my insurance

Student Parents Details (if under 18 years)
Parent's Name
Parent's Address
Parent's Telephone
Parent's Fax
Parent's E-mail

Courses

General English
     Full-time Part-time
     English Plus Private Tuition

Academic English
     High School Preparation Tertiary Preparation
     IELTS TOEFL TOEIC
     Pitman Cambridge

When would you like to start the course?

day		month		year
	/		/

(Courses start every Monday)

Your English Level
Beginner
Elementary
Lower-Intermediate
Intermediate
Upper-Intermediate
Advanced

Students enrolling for 24 weeks or more will be
tested before enrolment.

How long do you intend to study at the college?
weeks

How did you find out about this college?
Agent
Exhibition (Education Fair)
Advertisement
Internet
Others

Future Study Plans
High School
Foundation Study
Polytechnic
University/Tertiary
Others

Accommodation

Homestay (Please fill in the following information)

Homestay Information
How long do you intend to stay? weeks
Do you smoke?	Yes	No
Do you prefer a homestay with children?	Yes	No	Don't Mind
Do you prefer a homestay with pets?	Yes	No	Don't Mind
Do you have a health or allergy problems?	Yes	No
If yes, please explain
Are there any foods you do not like?	Yes	No
If yes, please explain
Hobbies

Other Accommodation
Bacpackers/YMCA
Motel
Flat
Others
Not Required

Contact us:
Canterbury Language College Australasia
Level 3, Link Centre, 152 – 156 Hereford Street
PO Box 4425, Christchurch, New Zealand
Phone +64 3 365 1920
Fax +64 3 365 2296
Email: info@cancan.com