Lingua Service Worldwide
Vacation 'N Learn ® Application Form

To Register for a program with Lingua Service Worldwide you must:
    1.  Complete the application form.
    2.  Return the application with a $100.00 application fee.
Please note: Presently, payment may not be made online.  Payment must be made by mail or fax.

Registration & Payment Options
1.  You may print out the application form (or contact us for a form) and send it to us by mail or fax along with your application fee.
2.  You may register online, and send payment separately by mail or fax indicating that you have registered online. 

Lingua Service Worldwide, Ltd. Phone (800)394-LEARN
42 Artillery Road            (203) 263-6294
Woodbury,  CT 06798 Fax:   (203) 263-6346

If applying online, please enter all information in the application form and submit it to us.  Please note that your registration will not be processed until we receive your registration fee. The Lingua Service Worldwide's brochure (printed and on-line) contains important information regarding programs, prices, accommodations and cancellation policies. You MUST understand the details of the program of your choice in order to fill out this application form, please read  the General Information page BEFORE filling out this form. 

Personal Information

First Name: Last Name: Title:

Street Address: Apt.:

City:  State:    Zip: Country:

Home Phone:   Work Phone:

Fax:       E-Mail:

Date of Birth: -- mm/dd/yy       Occupation: 
Civil Status: Single Married Divorced Widowed  Number of Children:
Education: High School  Associate    Bachelor     Master     Ph.D.
In case of Emergency:
Contact:  Relationship:  Tel:

Language Program

Language:   School Name:
School Location (city/country):
Course Type:Group Course  Private Course Special Course Name:
Starting Date:-- mm/dd/yy Arrival Date( If other than the day prior to the start of the course):
Number of weeks:     Hours per week:     Group Class Size:
Current Language Level: True Beginner  Advanced Beginner  Intermediate  Advanced

Accommodations and Meals

Accomodation Type:
Homestay   Residence Hall    Apartment Rental  Apartment Share
Hotel           None     Other      
Room Preference: Single   Double   Other  
Smoking Preference: Smoking      Non-Smoking  Either      
Meals: Full Board (3 meals)  Half Board (2 meals)  Breakfast Only   No-Meals            
Please indicate any special preferences, information or requests that you would like the school to consider when placing you (allergies, dietary concerns, young children in the home, etc..):


Payment

Payment Method:
Personal Check     Certified Check   Money Order    Bank Transfer      Credit Card     

Please note: Presently, payment by credit card can only be made by mail or fax. Do not submit your credit card information to us online.
Credit Card Type: Visa      Mastercard  
Credit Card Number: ______________________    Expiration Date:_______________    3-Digit Security Code from back of Card: ________

Signature:  Date:  -- mm/dd/yy

If under 18 years of age, Parent or Legal Guardian's Signature:  Date: -- mm/dd/yy

Comments(please enter any other relevant information that you would like us or the school to consider at this time):


Lingua Service Worldwide©.
Last revised: February 27, 2008