Name, first name:
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City:
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Age:

 

Level enrolled in:
Beginner	Intermediate	Advanced

 

Do you want to study French, English or Spanish?
French	English	Spanish

If yes, up to what level?

 

Duration of course desired (weeks ):
Approximate dates desired:

 

Accommodation preferred:
Host family	Motel / Hotel	Bed & Breakfast	Other
(specify):

 

You wish to receive tuition for:
Career advancement	Travel	Personal culture	Other
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What is the specific objective you wish to achieve by this learning experience?

 

Would you like to receive more or less than the suggested 25 hours of tuition per week?
Yes	No
If yes, please specify how many hours per week:

 

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École de langues Immersion 
135, rue des Érables 
Ste-Catherine-de-Hatley 
Quebec (Canada) J0B 1W0 
Tel.: (819) 868-2656 Fax.: (819) 847-2216 
rbedard@immersion.qc.ca