On-line enrolment

Personal informations

* Last name
* First name
* Sex		femalemale
* Birth date
* Place of birth (place of origin for Swiss)
* Nationality
* Mother language
* Language level		Beginner Elementary Lower intermediate Intermediate Upper intermediate Advanced Very advanced
Occupation
* Address
* Zip Code
* City
* Country		Andorra Afghanistan Albania Algeria Angola Anguilla Antarctica Antigua & Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fidji, Is Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Great Britain Greece Greenland Grenada, Is Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libyan Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru, Is Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau, Is Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russian Federation Rwanda Sainn Vicent & the Grenadines Saint Helena Saint Kitts and Nevis Saint Lucia, Is Saint Pierre and Miquelon Samoa, Is San Marino São Tomé and Príncipe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sandwich Islands Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu, Is Uganda Ukraine United Arab Emirates United States Uruguay Uzbekistan Vanuatu, Is Vatican City Venezuela Viet Nam Virgin Islands Wallis and Futuna Yemen Zambia Zimbabwe
* Home Tel.
Office Tel.
* Mobile
Fax
* E-Mail
Contact person during your stay
* Last name
* First name
* Home Tel.

Select course (s)

1)* City
* School
* Type of course
* Start date
* End date
* Number of weeks
2) City (to be filled in only if 2 destinations)
School
Type of course
Start date
End date
Number of weeks

Accommodation

1) * Start date
* Date of departure
* Accommodation type		Host family
		Campus residence
		Other
		No accommodation
Room		single
		double
Accommodation details		Half board
		Bed and Breakfast
		Full board
		Without meals
2) Start date (to be filled in only if 2 destinations)
Date of departure
Accommodation type		Host family
		Residence
		Other
		No accommodation
Room		single
		double
Accommodation details		Half board
		Bed and breakfast
		Full board
		Without meals
Preferences regarding host families
Non-smoking family		yes no don't mind
Family with children		yes no don't mind
Family with students		yes no don't mind
Family with animals		yes no don't mind

Accommodation extras

I am vegetarian		yes no
I smoke		yes no
Special diet
Allergies/Medical care
Hobbies, interests
Other comments

Flight / Airport transfer

* Flight offer		yes no
* Airport transfer		arrival departure no

Insurance

* I wish to take out a 3-month cancellation-assistance insurance (CHF 75.- / EUR 45.-)		oui non
* Extension of assistance insurance (CHF 10.50/EUR 6.30 per month)		yes. Number of months no
* I wish to take out an annual cancellation-assistance insurance, valid from the date of enrolment (under 26 years CHF 77.- / EUR 46.-) (over 26 years CHF 105.- / EUR 63.-)		yes no
* I wish to have free cancellation/examination protection (please send us certified proof of examination enrolment)		yes no

Confirmation & send

Promotional code
* How did you find out about ESL?		A friend I am a client Links Search engine Publicity (Internet) Newspaper Magazine Professional guidance School/university Poster/flyers Trade fair/exhibition Travel agency Other...
* Please specify
* I agree with all ESL's general terms and conditions .
		* Obligatory information

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