<p> Registration Form 2/15/12</p><p>STUDENT PERSONAL INFORMATION Name ______Last Name (Family Name) First Name Middle Name </p><p>Country of Nationality City of Birth Country of Birth Date of Birth ______month / date / year Gender (Circle one) Passport Number Visa type (Circle one)</p><p>Male / Female Student (F-1) Visitor (B-1/B-2) Visa Waiver (no visa) Other: ______Home Country Address</p><p>______Street Number Street Name Apt. Number </p><p>______</p><p>______City Province/Prefecture Country Postal/Zip Code </p><p>Home Country Contact Information (include Emergency Contact Information (include area/country area/country code) code) ______Home: ______Name of Emergency Contact Person and relationship</p><p>Cell: ______Home: ______</p><p>Fax: ______Cell: ______</p><p>Email address: Email address: ______ENGLISH COURSE</p><p>Course Dates Lessons per week (Circle one) Current level of English (Circle one) Start Date: ______Beginner Pre-Intermediate month / day / 16 20 25 year Intermediate Upper-intermediate Other: ______End Date: ______Advanced Fluent month / day / year</p><p>Global Village Hawaii 1440 Kapiolani Boulevard, Suite 1100, Honolulu, Hawaii USA 96814 Telephone: (808) 943-6800 Fax: (808) 943-6400 Emergency phone: (808) 341-0664 http://gvhawaiienglish.com Email: [email protected] Global Village Hawaii Registration Form downloaded from our website http://gvhawaiienglish.com Page 1 of 4 Registration Form 2/15/12</p><p>Total # of weeks: ______</p><p>Global Village Hawaii English Courses (Check requested course/s) □ General English □ Business English □ Cambridge Preparation □ FCE □ CAE □ TOEIC Preparation □ TOEFL Preparation □ Spoken English for Tourism Certificate □ Written English for Tourism Certificate □ Teen Activity Program</p><p>Global Village Hawaii Packages (Check requested package/s) □ English Plus (check one) □ Surfing □ Bodyboarding □ Hula □ Ukulele □ Yoga □ Fitness □ Academic Year □ Semester Gap □ Cambridge Support Package □ FCE □ CAE □ CPE □ Closed Study Tour Group □ Private Lessons □ Other: ______ACCOMMODATION </p><p>Do you want Global Village Hawaii to arrange your accommodation? □ Yes □ No If ‘Yes’, please answer the following questions.</p><p>Global Village Hawaii 1440 Kapiolani Boulevard, Suite 1100, Honolulu, Hawaii USA 96814 Telephone: (808) 943-6800 Fax: (808) 943-6400 Emergency phone: (808) 341-0664 http://gvhawaiienglish.com Email: [email protected] Global Village Hawaii Registration Form downloaded from our website http://gvhawaiienglish.com Page 2 of 4 Registration Form 2/15/12</p><p>Accommodation Option/s Requested Accommodation Dates □ Homestay □ Full Board (3 meals/day, single room) □ Roomstay (no Start Date: ______meals, single room) month / day / year (Please answer the homestay questions on page 3) □ Apartment End Date: ______</p><p>□ Kaimuki Residence month / day / year □ Standard Room □ Deluxe Room Total # of weeks: ______□ Kapiolani Residence □ Standard Room □ Deluxe Room □ YMCA □ Other: ______Airport Transfer Requested Flight Details – Arrival Flight Details – Departure </p><p>□ None Airline & Flight #: ______Airline & Flight #: ______</p><p>□ One way Arrival Date: ______Departure Date: ______month / day / month / year day / year □ Two way Arrival Time: ______Departure Time: ______Comments: ______</p><p> hour/minutes hour/minutes For Homestay Students Only Do you smoke? Do you have any allergies? If yes, Do you have any special dietary or please give details. health needs? If yes, please give details. □ No □ No □ No □ Yes □ Yes □ Yes</p><p>Comments: ______Comments: ______Comments: ______What are your hobbies or particular interests? </p><p>Will you live with a host family with: Smokers □ Yes □ No Dogs □ Yes □ No *Please note that it is not guaranteed that the student will Cats □ Yes □ No be matched with a host family having the exact criteria as Children □ Yes □ No the student’s requests. In every case, Global Village Other students □ Yes □ No Hawaii makes every effort to provide the best for the Other request/s: ______student.</p><p>Global Village Hawaii 1440 Kapiolani Boulevard, Suite 1100, Honolulu, Hawaii USA 96814 Telephone: (808) 943-6800 Fax: (808) 943-6400 Emergency phone: (808) 341-0664 http://gvhawaiienglish.com Email: [email protected] Global Village Hawaii Registration Form downloaded from our website http://gvhawaiienglish.com Page 3 of 4 Registration Form 2/15/12</p><p>How did you hear about Global Village Hawaii? □ Agent □ Friend □ Ad □ Website □ Other (e.g. Search engine (which one?), magazine, friend, embassy, fair or agent)</p><p>Please specify: ______Questions or comments:</p><p>DECLARATION</p><p>I have read and agree to be bound by the General Conditions and the Cancellation and Refund Policy and certify that the information provided on this registration form is correct. </p><p>Signature of Student: ______Date: ______(Signature of Parent/Guardian if student is underage) month/day/year</p><p>Print Name of Parent/Guardian: ______</p><p>Global Village Hawaii 1440 Kapiolani Boulevard, Suite 1100, Honolulu, Hawaii USA 96814 Telephone: (808) 943-6800 Fax: (808) 943-6400 Emergency phone: (808) 341-0664 http://gvhawaiienglish.com Email: [email protected] Global Village Hawaii Registration Form downloaded from our website http://gvhawaiienglish.com Page 4 of 4</p>