Register for Language Program

First Name:
last name:
E-mail:
street address 1:
street address 2:
city:
state/province:
zip/postal code:
country:
telephone #:
fax #:
country of birth:
date of birth:	(dd/mm/yyyy)
gender:	male    female
native language:
will you be applying for a study Permit?	no yes
who will pay for your course?	self / parents     others, please specify:
emergency contact, full name:
emergency contact, telephone #:
how did you hear about M.I.I.L.A?	Internet Print advertisement Word of mouth Friend / former student Educational fair, please specify:

Start Date (dd/mm/yyyy) to Desired End Date (dd/mm/yyyy) for a total of weeks

Programs
which Language Would you Like to study?	English French Spanish (evening or private courses only)
How many hours per week?	Intensive (30 hrs/week) Regular (22.5 hrs/week) Part-time (15 hrs/week) Evening (6 hrs/week) Private
current language level:	Beginner Intermediate Advanced
Accommodation
Will you require accommodation?	No Residence (no meal) Homestay (2 meals) Homestay (3 meals)
From (dd/mm/yyyy) to (dd/mm/yyyy) for weeks and days
Questionnaire for Homestay only
Homestay family language:	English speaking
	French speaking
Do you smoke?	No     Yes
Do you have allergies?	No     Yes
Do you take daily medication?	No     Yes
Is there any food you cannot eat?	No     Yes
Can you live with children?	No     Yes
Would you mind to live with pets?	No     Yes
Airport pick-up
Will you require airport pick-up?	No     Yes, please specify the arrival information:
Medical insurance
Will you require medical insurance?	No     Yes
From (dd/mm/yyyy) to (dd/mm/yyyy) for weeks and days

The payment of the CAD$100 registration fee is required in order for M.I.I.L.A. to process your registration.
If you wish to make this payment by credit card, you can use our PayPal online payment link. Once you have completed the payment on PayPal, you will be redirected to our website in order to complete this registration form. Do not forget to write down in the transaction I.D. box below the transaction I.D. number given to you by PayPal.

	Credit card
	Please write the transaction I.D. number given to you by PayPal
	Money order, traveler's cheques or certified cheques in CAD$
	Make payable to Montreal International Institute of Language Arts. Mail to: Montreal International Institute of Language Arts 1222 Mackay street, Suite 300 Montreal, Quebec. H3G 2H4. CANADA
	Wire transfer in CAD$
	Wire payment to: Montreal International Institute of Language Arts Account number: 5215961 Branch number: 05271 SWIFT number: TDOMCATTTOR TD Canada Trust 999 De Maisonneuve Blvd. West Montreal, Quebec. H3A 3L4. CANADA Fax: +1 (514) 847-8955