Application Form

Last (Family) Name
First Name	Male Female
Email Address
Address
City
Province/State
Country
Postal Code
Telephone
Fax
Citizenship
Birthdate	e.g. 1975/05/30
Visa Classification	Student Visitor Working
What is your current level of English?
Which course are you applying for?
When do you wish to begin?
How many weeks will you study for?
Arrival Date
How did you hear about Heartland?

Accommodation Information

Do you want to stay in a Homestay?	Yes No
Do you want to stay in a residence?	Yes No
	Please choose only one accommodation option
Any medical conditions?
Any allergies?
Would you live with a family that:
has children?	yes no doesn't matter
has pets?	yes no doesn't matter
smokes?	yes no doesn't matter
has another international student?	yes no doesn't matter

Do you need Airport Pick-up? (airport pickup is free if staying in one of Heartland's Homestays or Residences)	Yes No
Flight information:
Arrival date:
Arrival time:
Airline:
Flight number:
Do you have medical insurance?	Yes No
If yes, please indicate:
Insurance Provider:
Policy #:
Dates of Coverage:

Please review the above information is accurate and correct BEFORE clicking submit.

FEES ARE SUBJECT TO CHANGE, UNLESS PAID IN ADVANCE. ALL FEES SHOULD BE PAID DIRECTLY TO THE SCHOOL. HEARTLAND INTERNATIONAL ENGLISH SCHOOL ASSUMES NO RESPONSIBILITY FOR MONEY PAID TO COMPANIES OR INDIVIDUALS CLAIMING TO REPRESENT THE SCHOOL.

- HEARTLAND INTERNATIONAL ENGLISH SCHOOL WILL NOT BE LIABLE IN ANY WAY TO THE STUDENT FOR LOSS, DAMAGE, OR INJURY TO PERSONS OR PROPERTY HOWSOEVER CAUSED.

- ALL FEES ARE IN CANADIAN DOLLARS.

I ACKNOWLEDGE THAT I AM FULLY RESPONSIBLE FOR MY OWN MEDICAL INSURANCE. I HAVE READ, UNDERSTOOD AND AGREE TO COMPLY WITH SCHOOL POLICY REGARDING TUITION FEES AND REFUNDS. IF I BECOME ILL OR INCAPACITATED, HEARTLAND INTERNATIONAL ENGLISH SCHOOL AND ITS EMPLOYEES MAY TAKE ANY REASONABLE ACTION THEY DEEM NECESSARY FOR MY OWN SAFETY AND WELL-BEING.