Cathedral City Academy

There are two ways you can enrol:

1. You can complete the online form below, or
2. Print a form from this web page byclicking here and then fax it to us.

PERSONAL DETAILS

Family Name: First Names: Male Female

Nickname or name you liked to be called:

Date of Birth: Day: Month: Year:

Home Address:		Telephone:
Home Address:		Email:
City:		Mobile:
Country:		Fax:
Passport number:		Nationality:

Visa type: Visitor Student Working Holiday Other

Current Occupation OR University/School:

Name of course:

EMERGENCY CONTACT DETAILS (Parents or family members in your OWN country)

Name: Relationship to you:

Does this person speak English? Yes No

Address:		Telephone:
		Email:
		Fax:

Do you require a homestay?
Yes. Please complete the section below.
No. I would like information on other accommodation.

Future plans in New Zealand:
Working Holiday Holiday University High School Other

HOMESTAY DETAILS

Homestay fees

3 meals per day, 7 days per week	$224.00 Per week (7nights)	Additional nights $32 per night
homestay placement fee	$120.00
homestay change fee	$50.00

Start date: (dd/mm/y) //200 End date: (dd/mm/y) //200
Number of weeks: Extra nights:

Do you smoke? Yes No Sometimes

Are there any foods that you don't eat? Yes No
If YES, what foods?

I would prefer a family: With pets Without pets Don't mind
With children Without children Don't mind

Hobbies or interests:

Your Personality - Independent Confident Shy Tidy Dependent Quiet Untidy

INSURANCE DETAILS

It is COMPULSORY for you to have Travel and Medical insurance while in New Zealand. CCA can arrange excellent insurance for you. Please tick the policy length that you need (in NZ$). (Insurance cover is subject to acceptance by the insurance company and costs are subject to change.)

Would you like to arrange your insurance ?
Yes No

3 months $125 6 months $228 9 months $342 12 months $456

Do you have any allergies or medical conditions? (Asthma, diabetes, heart problems, etc)
Yes No

If yes, please give details:

If you have arranged your own medical and travel insurance, please tell us the name of your medical insurer and the Policy Number.

Insurer: Policy Number:

IMPORTANT!
If you are arranging your own insurance by yourself, please send or fax us a copy of your Insurance Policy documents in English BEFORE leaving your country to:
CCA, PO Box 1412, Christchurch, New Zealand or fax us on: 64 3 366 0742
Note; CCA will NOT accept policies that don't meet minimum level of cover outlined.

COURSES REQUIRED (Subject to minimum numbers)

Full time Part time General English General English for Employment IELTS
English Plus Volunteer Paid Work

Start date: (dd/mm/y) //200 End date: (dd/mm/y) //200
Number of weeks:

Past English Study: Number of Years: Number of Months:

Present level of English:
Beginner Elementary Pre-Intermediate Intermediate Upper Intermediate
Advanced

How did you find out about Cathedral City Academy?
Internet Friend Agent CCA Brochure Magazine Other

Any comments or questions:

I have completed all enrolment details truthfully and request enrolment at Cathedral City Academy. I have read and accepted all of the conditions (part of the enrolment form PDF file) .

2008 Cathedral City Academy