2015 F%%3&
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2n
2nd
nd Fl
Floor
loor – 294 William Avenue
Winnipeg,
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W
nipeg, Manitoba, Canada R3B 0R1
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WEEKS
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(OURSPER7EEK
(OURSPER7EEK
0RICES0ER7EEK
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/THER&EES
!PPLICATION&EE.ONREFUNDABLE
!PPLICATION&EE.ONREFUNDABLE
4EXTBOOK
4EXTBOOK
(OMESTAY!CCOMMODATION
3TUDENT2ESIDENCE
0LACEMENT&EE (Nonrefundable)
$200
2ED2IVER#OLLEGE2ESIDENCE
(OMESTAY&EE (3 meals/day)
WEEK
#USTODIANSHIP&EE (Under 18)
$100
(OMESTAY%XTRA.IGHT
(OMESTAY%XTRA.IGHT
(OMESTAY&EES
0LACEMENT&EE(Non-refundable)
$200
3ECURITY$EPOSIT(Refundable) !CCOMMODATION
3INGLEORDOUBLEDORM
3INGLEORDOUBLEDORMINCLUDING
MANDATORYMEALPLAN(8 meals/week)
MONTH
7ILLIAM#ATHERINE"OOTH#OLLEGE
/THER&EES
!IRPORT0ICKUP
(when staying in a
Heartland accommodation)
&2%%
0LACEMENT&EE(Non-refundable)
$200
3ECURITY$EPOSIT(Refundable) !CCOMMODATION
3INGLEORDOUBLEDORM
3INGLEORDOUBLEDORMINCLUDING
MANDATORYMEALPLAN(10 meals/week)
!IRPORT0ICKUP
MONTH
(when NOT staying in a
Heartland accommodation)
3TUDENT)NSURANCE
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DAY
Test Fees
#OURIER3ERVICE
#OURIER3ERVICE
$100
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(May be higher depending
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s0LEASE.OTE: Prices are subject to change without notice.
2015 A00,)#!4)/.F/2Student Information
Family Name: ________________________________________________________________________________________________________________________________ Given Name: ____________________________________________________________________________________________________
Male
Female
Date of birth (Year/Month/Day) ______________________________________________________________________________ Citizenship _____________________________________________________________________
Address: ____________________________________________________________________________________________________________________________________________________________________________ City: _________________________________________________________________________________
Province/State: ________________________________________________________________________________________________________ Country: ____________________________________________________________ Post Code: ______________________________________________
E-mail: _______________________________________________________________________________________________________________
Telephone: ____________________________________________________________________________________________________________________________________
Emergency Contact Name: ________________________________________________________________________________________________________________________________ Emergency Tel: ( ________________ ) _________________________________________________
Status in Canada: Student
Visitor
Work
Other
______________________________________________________________________________________________________________________________________________
Course Information & Fees
Study Schedule: Semi-Intensive (15 hrs/wk)
Intensive (25 hrs/wk)
Super-Intensive (33 hrs/wk)
Start Date (Year/Month/Day) ________________________________________________________________________________________________________________________
Number of Study Weeks ______________________________________________________________
Accommodation Information
Homestay (Full board: 3 meals / day and private room)
Red River College Residence
IELTS Preparation (8 hrs/wk)
Booth College Residence
Please make us aware of any additional
special homestay requests
I will make my own accommodations
Accommodation Start Date (Year/Month/Day) _____________________________________________________________________________________________ Length of Stay: _____________________________________________________________________________
Do you smoke? (Note: Most families do not allow smoking indoors)
Are you okay living in a home with pets?
Do you have any food restrictions?
Yes
Yes
No
No
No
Do you have any medical conditions or allergies?
Yes
If yes, please specify? ____________________________________________________________________________________________________________________________________
Yes
No
Are you okay living in a home that is hosting other students?
Yes
If yes, please specify? ___________________________________________________________________________________________________________
No
Are you okay staying in a home with children?
Yes
No
What are your hobbies/interests? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________
Arrival Information
Do you need airport pick-up?
Yes
No
(Please note airport pick-up is FREE only if you are staying in a Heartland accommodation)
Arrival Date: _______________________________________________________________________________________________ Arrival Time: _______________________________________ Airline and Flight No.: __________________________________________________________
Medical Coverage
It is mandatory that all students have medical insurance coverage throughout their stay at Heartland. Students with a valid study or work permit
for 6 months or longer are eligible for free Manitoba Health coverage. Students with a visitor permit or staying under 6 months must purchase insurance.
Insurance can be purchased from Heartland for $2 per day or arranged independently.
Do you need Medical Insurance from Heartland?
Yes
No
If no, please provide your insurance details: Provider: ___________________________________________ Policy # __________________________________________ Date of Coverage
__________________________________________
Student Declaration
I declare that the information I have provided is correct and accurate. I have read and understood all of Heartland’s policies.
STUDENT SIGNATURE ________________________________________________________________________________________________________________________________________
Fax Application to (204)
Fa
Date: ______________________________________________________________________________________
989-2232 or Email to [email protected]
2015 P2/'2!-34!24$!4%3
3
January
5
12
19
26
February
2
9
April
6
13
20
27
May
4
11
July
6
13
20
27
August
4*
October
5
13*
November
2
19
26
10
9
17*
23
19*
25
17
24
16
23
31
30
Tuesday start dates
es
due to holidays
March
2
9
16
23
30
June
1
8
15
22
29
September
8*
December
7
14
14
21
21
28
28
2015 (/,)$!93 (No School)
Louis Riel Day
Canada Day
Monday, Feb.16
Good Friday
Wednesday, July 1
Terry Fox Day
Thanksgiving Day
Monday, Oct. 12
Friday, April 3
Monday, Aug. 3
Remembrance Day
Wednesday, Nov. 11
Victoria Day
Monday, May 18
Labour Day
Monday, Sept. 7
Christmas Day
Payment Options
Refund Policy:
Bank Transfer:
Cash (In person only)
Cheque
Money Order
Visa/MasterCard
Debit Card (In person only)
Friday, Dec. 25
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TD Bank
TD Centre Branch
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Heartland will refund all the fees expect
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the school will refund 50% of the tuition
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Credit Card Authorization: Instructions
1. Complete the form in the blanks below.
2. Print the form and have the credit card holder sign on the line indicated below.
3. FAX (1-204-989-2232) OR scan and email ([email protected] ) the completed form to process your payment.
I, _____________________________________________________________________________ , hereby authorize Heartland International English School
to charge my credit card account in the amount of $ _________________________________________.
Visa
MasterCard Credit Card No. ______________________________________________________________________________________________________________
Expiry Date: __________________________________________________________
Credit Card Billing Address:
Street: ___________________________________________________________________________________________________________________________________________________________
District/State: _______________________________________________________________
Telephone: ( ________________ )
City: ___________________________________________________________________________________
Postal Code: _________________________________________________________________ Country:
_____________________________________________________________
________________________________________________________________________________________________
As the credit card holder, I hereby authorize payment for the fees indicated above.
_______________________________________________________________________________________________________________________________________________________________________________________
Cardholder’s Signature Date
Date:
________________________________________________________________