English Language Institute - Westchester Campus
78 N Broadway, Aloysia Hall 303B
White Plains, NY 10603
Tel: (914) 422-4042
[email protected], http://www.pace.edu/eli
Registration Form for Au Pair Students
Instructions for Registration: Send or br ing the completed r egistr ation sheet along with a check or
money order payable to “Pace University.” If host families are paying the tuition, the au pair’s name should
be written in the memo section of the check. Please send separate checks for courses in different sessions
(ex. Spring I & Spring II) or different programs (ex. Saturday & Evening). If you use a money order, please
bring it with you to our office or mail it with a tracking number for your own security. ELI cannot be responsible for money orders lost in the mail. Registration must be received before the start of the course. Sign the
payment policy on the page 2. Please read the parking directions and avoid parking in the restricted areas to
avoid receiving a ticket.
(circle one) Saturday / Evening/ Weekday Morning
Spring I, Spring II, Summer I, Summer II, Fall I, Fall II Year ________
Name of Course(s)___________________________, _____________________________
Name: ________________________________ _________________ New student: YES, NO
Last
First
Mailing Address: __________________________________________________________________________________
Street
Apt.
Cell Phone: __________________
City
State
Zip
E-mail (write clearly):_________________________________________________
Birthday: (MM/DD/YY) ___________________
Gender: Male or Female (circle one)
Country of Citizenship: _______________ Country of Birth: ______________ Native Language: ________________
Name of Au Pair Agency_________________Au Pair Coordinator’s Name & Email: __________________________
Student Signature: _____________________________
PLEASE DO NOT WRITE BELOW. FOR OFFICE USE ONLY
Pace ID Number:
Course Title
Opening Date
Subject
ELI
ELI
ELI
ELI
Tuition Discount (C766)
Total
ELI Staff Signature __________________________
Course #
___________________
CRN
$Amount
Payment and Refund Policies (please read carefully)
PAYMENT TERMS
Full payment is due at the time you register. Please pay with a check or a money order payable to Pace University.
Be sure to include your name on the check.
REFUND POLICIES
If a student notifies ELI of intention to withdraw:
prior to and during first week of term
during the second week of term
after the second week of term
6-week course
100% refund
25% refund
no refund
7-week course
100% refund
50% refund
no refund
To receive a refund, notify us by email your intention to withdraw from class according to the above schedule. All
refund checks will be payable to the student per university policy.
I have read, understand, and agree to the Payment and Refund Policies.
__________________________________________________________
Signature of Client/Student (REQUIRED)