ECN Enrolment Form

* Family Name:

Please provide your Family name.

* First/Given Name:

Please provide your First/Given name.

* Gender: Female Male

Please indicate your gender.

Date of Birth: (D/M/Y)

Please provide your date of birth.

Nationality:

Please provide your Nationality.

Passport No.:

Please provide your Nationality.

* Address (Home Country):

Please provide your Home Country Address.

* Address (New Zealand):

Please provide your New Zealand Address.

* Email:

Please provide a valid email address.

* Phone No.:

Please provide your phone number.

Mobile No.:

Please provide your mobile number.

* Type of VISA:

Please provide your VISA type.

General English: Full Time with Conversation Full Time with Reading & Writing Full Time - English for Living and Working Part Time - AM Part Time - PM

Survival English for Living and Working: 4 hours a week in evening

IELTS Preparation: FULL TIME PART TIME

High School Preparation: FULL TIME

Teacher Training: TESOL + TAK Course Intensive TESOL Course

Do you require a TKT Exam? Yes No

* Date you wish to start? (D/M/Y)

Please provide a study starting date

* How long do you wish to study? (in Weeks)

Please enter how long your wish to study for.

* Do you require accommodation? Yes No

Please enter if you require accommodation.

If Yes? Hostel Homestay

Please enter if you require a hostel or homestay.

How long do you wish to stay? (in weeks)

Please enter the number of weeks you will be staying for.

Accommodation Start Date: (D/M/Y)

Please enter the start date for your accommodation.

Is there any food you cannot eat?

Please enter any food that you cannot eat.

Do you smoke? Yes No

Please indicate if you smoke or not.

Do you have any health problems or allergies?

Please indicate if you have any health problems or allergies.

What are your hobbies or interests?

Please indicate if you have any hobbies or interests.

Homestay preference Without children With children With pets Without pets Sharing a room with other student

Please indicate if your homestay preferences

If No: I have my own accommodation

Address:

Please indicate the address you are staying at.

Phone:

Please indicate the phone number for the place you are staying at.

Young student (under 18 years old) not with an ECN Homestay

Please choose form the following: Parent / Legal Guardian Designated Caregiver appointed by parent / legal guardian

Please indicate the phone number for the place you are staying at.

Arrival Date: (D/M/Y)

Please indicate your arrival date.

Arrival Time:

Please indicate your arrival time.

Airline and Flight Number:

Please indicate your Airline and Flight Number.

Do you want airport pick-up service? Yes No

Please indicate if you need an airport pick-up service.

All students are required to have medical and travel insurance I have arranged my own insurance Please organise it for me

Please indicate if you have organised your own insurance or if you want us to organise one for you.

If you want us to organise your insurance, how many months do you need?

(Southern Cross Educational Travel Insurance Service)

1 month	$50	2 months	$100	3 months	$125	4 months	$152
5 months	$190	6 months	$228	7 months	$266	8 months	$304
9 months	$342	10 months	$380	11 months	$418	12 months	$456

(price for StudentMax plan, price subject to change)

Please indicate how many months of insurance you require.

Enrolment Form

PERSONAL DETAILS

COURSE DETAILS

ACCOMMODATION

ARRIVAL DETAILS

MEDICAL INSURANCE

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