| Part A: Program Option |
| Please select a program option:* |
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| Part B: Student’s Basic Information |
| Last Name:* |
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| First Name:* |
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| Gender:* |
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| Birth Date:* [If you are over 18, you are not eligible for this program] |
Month Day Year |
| Nationality:* |
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| Country of Residence:* |
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| Native Language:* |
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| How was student referred to this program:* |
Other:
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| Part C: Participant Contact Information |
| Home Country Address:* |
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| Home Country City:* |
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| Home Country Postal Code:* |
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Home Telephone:* [include country/city code]
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Mobile Phone:*
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| Email Address:* |
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| Skype ID: |
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| Name of parent or guardian:* |
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| Email Address of parent or guardian:* |
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| Telephone Number of parent or guardian:* |
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| Emergency Contact Information |
| Last Name:* |
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| First Name:* |
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| Telephone number :* [include country/city code] |
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| Relationship:* [ex: mother, father, aunt, uncle] |
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| Part D: English Level |
| What is the student’s present level of English:* |
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| How many years has the student studied English?* |
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Please give details of any English courses
and examinations taken (date takes/grade achieved): |
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| Other Languages Spoken: |
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| Part E: Medical/Personal Information |
| Does the student have any allergies to food, drugs, animals or environmental factors?* |
If Yes, please list below:
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| Please list any medication the student takes and indicate the condition it treats, if applicable. |
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Please list any special dietary requirements, (e.g. vegetarian), if applicable.
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| Has student had any medical/psychological or social problems?* |
If Yes, please explain below:
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Please list personal interests such as hobbies, favorite types of music, sports, movies, etc...
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| Part F: Travel, Visas, Permission to Travel |
It is the responsibility of the student’s parents/guardians to contact their local consulate (or other appropriate office)
in sufficient time to obtain any visas/entry documents for visiting the United States.
Please check that you have read and understood the above.*
Note that participants must arrive on designated arrival dates at designated airport and depart on designated departure dates at designated airport, between 9:00 a.m. and 6:00 p.m. Arrivals and departures outside of those dates/times will be considered on a case by case basis and will incur additional charges.
Participants who will arrange their own transportation to and from the SEA location must advise CCI of these arrangements beforehand via email. |
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