ESL Program Application

First Name *

Middle Name

Last Name *

Address *

City *

State

Country *

ZIP Code *

Telephone *

Email Address *

Country of Citizenship

Which sessions do you wish to attend? *

Spring 2 (March and April) Summer Fall 1 (September and October) Fall 2 (November and December)

For all students: I understand that the English Language Institute has a strict attendance policy. Attendance is required in all classes and is closely monitored. Students are required to sign into class, participate in class, do homework and complete English Placement tests every 7 weeks.A student visa requires full time attendance.

I understand this attendance policy *

Yes No

Have you taken the TOEFL English Test or any other English Placement test? *

Yes No

Test Information

Name of Test:

Date Taken:

Score:

Note: All students who require a visa must email a picture of their passport to us.

Do you need a student (F-1) visa?: *

Yes No

Do you already have a student visa?: *

Yes No

Do you wish to transfer that visa from another school?: *

Yes No

Do you already have a United States visa and you wish to change your visa status?: *

Yes No

I plan to attend the *

Full-Time Intensive Program (20 hours per week) Part-Time

Sponsorship Information

Person responsible for paying. Only required for student visas.

Name of Sponsor Organization:

Name of Sponsor or Academic Advisor Information:

Sponsor ID number:

Sponsor Email:

Will you have a dependent that will be traveling with you?:

Yes No

Dependent Information

Only required for student visas.

Name:

Date of Birth (Month/Day/Year):

Country of Citizenship:

If more than one dependent, please add their names and date of birth.

Other Dependents

For all applicants and dependents, a copy of their passport is required.

Apartment Information

For home stay and apartments, a 2 month deposit is required.

Would you like us to arrange housing for you?: *

Yes No

What kind of apartment would you like? (6 month minimum stay required)

Single apartment Shared apartment

Dates Required:

Budget:

$900 to $1100 $1100 to 1300 $1300 to $1500 more than $1500

Do you smoke?:

Yes No

Yes. I want to purchase health insurance through SHU. I understand that insurance costs $65 per month:

No. I do not want to purchase health insurance from SHU. I have my own. (Please note: If no, proof of insurance will be required at registration time):

Yes. Please arrange airport pick-up service for me. I understand that this service costs $145. I understand I need to pay for this in advance:

No. Please do not arrange airport pick-up service for me:

Yes, I want help getting a mobile phone when I arrive:

Yes, I want help opening a bank account when I arrive:

Emergency Contact

In case of emergency, whom should SHU contact?

Name: *

Must be a family member or a personal friend

Relationship: *

Email: *

Country of Citizenship *

More Information

What is your current profession:

How did you find out about us?

What would you like to study after ESL?

Undergraduate Graduate

Major:

Do you have a bachelor’s degree?:

Yes No

Major Studied:

Have you completed a credit evaluation:

Yes No

Please send my Acceptance Packet (including my I-20 form if I applied for one)

to the permanent address above to a different address (type in below) Myself or someone else will pick up

Payment Information

Once you submit this form, you will be provided a link to pay your fee's using a credit or debit card.

I would like to pay my fees with a credit card or debit card:

Financial Certification, Housing Deposit Guarantee & Medical Authorization

By submitting this online form, you are allowing Sacred Heart University English Language Institute to process your application.