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A2Z Languages on-line Registration Form

Please take your time and fill out the form carefully. If you have any questions, please do not hesitate to contact us.

(Fields marked with * are required to be filled in)

First Name *
Last Name *
Street Address *
City *
State / Province *
If in the US
If not in the US
ZIP *
Country *
Home Phone *
Work Phone
Fax
E-mail *
Date of Birth
Day
Month
Year
Sex
Male Female
Marital Status
Single Married
Occupation
If Other:
Nationality *
Emergency Contact
Name
Phone
How did you hear about us?
If Other:
Language Level
Language Level Comments
What other languages do you speak?
Program and Accommodation Information #1
Program #1
Lessons/Day Weeks
Type In Name Of Program You Want To Enroll In (For example Group Class 4 hrs per day)

School Dates

Note: Classes begin on Mondays and terminate on Fridays. Your accommodation will begin on a Sunday and terminate on a Saturday.

Start Date:

Day
Month
Year
 
 

End Date:

Day
Month
Year
 
Applying for Academic Credit?
Yes No
From which institution (if applying for credit) USM

Seattle Central CC

Other
Reason for Choosing location/school:
Expectations:
Accommodation Preferences For Program #1
Live with family?
Yes No
Live in student residence or apartment?
Yes No
If yes, indicate type of Res/Apt (some locations only offer one choice)
How many meals? : (Some locations only offer one choice).
Room type
Private Shared
Are you traveling with a companion?
Yes No
Name of companion
Same accommodation?
Yes No
Share a bed?
Yes No
Total Amount of Fees & Costs for Program #1. This is your estimate only
Program And Accommodation Information #2
Program No. 2
Lessons/Day Weeks
Type In Name Of Program You Want To Enroll In (For example Group Class 4 hrs per day)

School Dates

Note: Classes begin on Mondays and terminate on Fridays. Your accommodation will begin on a Sunday and terminate on a Saturday.

Start Date:
Day
Month
Year
 
 
 

End Date:

Day
Month
Year
 
 
 
Applying for academic credit?
Yes No
From which institution (if applying for credit) USM

Seattle Central CC

Other
Reason for Choosing location/school:
Expectations:
Accommodation Preferences For Program #2
Live with family?
Yes No
Live in student residence or apartment?
Yes No
If yes, indicate type of Res/Apt (some locations only offer one choice)
How many meals? : (Some locations only offer one choice).
Room type
Private Shared
Are you traveling with a companion?
Yes No
Name of companion
Same accommodation?
Yes No
Share a bed?
Yes No
Total Amount of Fees & Costs for Program #2. This is your estimate only
If you are only applying for programs in two locations click here!
Program And Accommodation Information #3
Program No. 3
Lessons/Day Weeks

Type In Name Of Program You Want To Enroll In (For example Group Class 4 hrs per day)

School Dates

Note: Classes begin on Mondays and terminate on Fridays. Your accommodation will begin on a Sunday and terminate on a Saturday.

Start Date:
Day
Month
Year
 
 
 

End Date:

Day
Month
Year
 
 
 
Applying for academic credit?
Yes No
From which institution (if applying for credit) USM

Seattle Central CC

Other
Reason for Choosing location/school:
Expectations:
Accommodation Preferences For Program #3
Live with family?
Yes No
Live in student residence or apartment?
Yes No

If yes, indicate type of Res/Apt (some locations only offer one choice)
How many meals? : (Some locations only offer one choice).
Room type
Private Shared
Are you traveling with a companion?
Yes No
Name of companion
Same accommodation?
Yes No
Share a bed?
Yes No
Total Amount of Fees & Costs for Program #3. This is your estimate only
A2Z Languages tries to honor all requests relating to your accommodations. However, sometimes this is NOT POSSIBLE.
Request
Children
Smokers
Dietary Concerns
Medical Conditions
Other Comments
Yes
No
No Preference
Airport Pick-up Information
(Required no later than 2 Weeks before arrival)
Arrival Date
Day
Month
Year
 
 
 
Arrival Time
Airline Name
Flight Number
Airport Pick-up (This option is not offered at all locations)
Yes No
Note: If you don't have your flight information at this time, you can still submit a registration form. In fact it is HIGHLY recommended that you get a confirmation back from us before you purchase airline tickets.
Payment Information
To process your registration you MUST SUBMIT payment information. If you do not wish to submit payment information on this form you must either call our office or fax us payment information.
A2Z Languages accepts the following cards:
American Express Credit Card
Click on the logos above to find out about the American Express Fraud Protection Guarantee & the VISA Zero Liability Program
Credit Card Type
Cardholder's name
Credit Card No.
Expiration Date
Amount to be charged ($90 is required to process the registration)
Any other comments about your program:

Accept Terms & Conditions

By Submitting Your Registration On-line, You Agree To The Fact That You Have Read Our Registration Policies, Understand The Policies, And Agree To Abide By The Policies.

 

  

 

 

 

A2Z Languages •3219 East Camelback Road #806 • Phoenix, AZ 85018 USA
Toll Free (USA & Canada) 1-800-496-4596 • Outside the USA & Canada: 1-602-778-6794 • FAX: 1-602-840-1545
Website:
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