Application Form Please type or use block letters when you ...

Gateway Student Application Form Please type or use block letters when you complete this form. Personal Information How to Enroll Family Name________________________________________________ First Name____________________________________ Please complete the application form and submit the following in an envelope:

Birth Date (Month/Day/Year)____________________________________ Gender Country of Origin Address___________________________________________________________________________________ City_______________________________________________ State/Region__________________________________________ Country____________________________________________________ Postal Code___________________________________ Home Telephone____________________________________________ Other Telephone________________________________ Fax_______________________________________________________ E-mail________________________________________

 Gateway Application Form  $125 application fee (do not send cash)

 Statement of Sponsor Support  Proof of financial responsibility (see Statement of Sponsor Support)

 A photocopy of the student’s current passport

 Additional service fees if applicable

Country of Birth_____________________________________________ Nationality_____________________________________ Send to: Number of years of studying English______________ ADMISSIONS 384 West Center Street Provo, UT 84601 USA How did you learn about Nomen Global

Poster _________________

Tel: (801) 375-7878 Fax: (801) 375-7767 E-mail: [email protected]

Person to notify in case of emergency: Full Name_____________________________________________________________ Full Address___________________________________________________________________________________________ _____________________________________________________________________________________________________ Telephone Number____________________________ Fax__________________________ E-mail_______________________

Course Information Course Name ________________________________________________________________________________________ Start Date (Month/Day/Year) __________________________________ Number of Weeks ___________________________ For what purpose do you wish to learn English? _____________________________________________________________ ___________________________________________________________________________________________________

Health Information Do you have any special medical restrictions or conditions such as allergies, dietary restrictions or physical handicaps that we should be aware of and consider? No. Yes, please specify:_____________________________________________

Additional Fees Express Mail Fee - $75 Express Mail Fee is required if we ship your I-20 internationally. Apartment Location Fee - $225 Homestay Location Fee - $225 Please send the Apartment/Homestay Location Fee if you wish Nomen Global to find housing for you. Airport Transfer Fee - $75 (arrival) $75 (departure) Please send Airport Transfer Fee if you wish Nomen Global to meet you at the airport upon arrival to shuttle you to your accommodations. Nomen Global must receive your request, your flight number, and your arrival time at least 14 days prior to your arrival or departure.

Housing Do you wish Nomen Global to find accommodations for you? (See additional fees at right.) No, I will find my own accommodations. Yes, please contact me with more information about housing opportunities.

Airport Transfer Airport Transfer is included in the American Adventure Youth Program. No, I will find my own transportation. Yes, please contact me with more information about Airport Transfer Service.

Insurance Information

Payment Payment of tuition and fees must be made in full upon arrival to the U.S. Nomen Global accepts U.S. dollars, traveler’s checks, Visa, MasterCard, and bank checks made payable to Nomen Global Language Centers. Please do not send cash through the mail.

Health Declaration

Insurance can be purchased either before leaving for or after arriving at Nomen Global. All international students must have health insurance coverage during their entire stay in the United States.

I am aware that I must arrange for medical insurance for the total duration of my stay in the USA. In the event of a medical emergency during my stay in the USA, I authorize any licensed hospital or I confirm that I have read and accepted Nomen Global’s General Terms and Conditions, including the cancellation and refund physician to initiate treatment, and to Policies as well as the policy on sponsor access to grades. I realize that I am fully responsible for my financial obligations and viability while release medical information for diagnostic studying at Nomen Global and will be held accountable for maintaining the terms of this statement. and insurance purposes for follow-up Signature____________________________________________________________Date_______________________________ treatment in my home country at my cost. I absolve Nomen Global and its representatives from any liability for such Signature of Parent/Guardian____________________________________________Date_______________________________ measures taken on my behalf. (if applicant is under 18 years of age) I am also aware that these declarations, required by the American government authorities, are legally binding when Nomen Global accepts my application.

Signature

Adopted 9/2012

III.1.a.