Canadian Language Learning College , Study English ESL in Canada -Regiistration Form

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*	First Name:
*	Last_name:
*	E-mail:
	Country:
	Telephone:
	Cell Phone:
	Male / Female:
	Passport Number:
	Birthdate:
	Home Address:
	City:
	Province / State, Country:
	Postal Code:
	Program Selection:
	Start Date:
	How Many Weeks:
	Medical Insurance:
	Do you want a Homestay?:
	Do you smoke?:
	Do you have allergies?:
	Do you take any medications?:
	Do you any health problems we should know of?:
	If Yes, explain:
	Do you have any special questions or concerns about Homestay?:
	Do you want CLLC Pick Up Service?:
	How will you arrive?:
	Arrival Date (if you know):
	Arrival Time:
	Flight Number:
	From What City will you be arriving to Halifax?:
	Other Info about your arrival:
	Did you use and Agent to register at CLLC?:
	If Yes, what is the Agency Name?:
	Was this agent helpful and informative?:
	Comments about agency?:
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