Compulsory (*)
Name, first name:
Address:
City:
Province:
*Country (Postal Code):
*Phone:
Fax:
*E-mail:
Age:
Level enrolled in:
Beginner Intermediate Advanced
Do you want to study French, English or Spanish?
French English Spanish
If so, up to what level?
In which city would you wish to learn French? Choose a city Magog Montreal Quebec City
Comments regarding that choice:
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

Specify:

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:

Do you have any comments, suggestions or information?

Please enter the validation code to validate your enrollment:

All rights reserved © 2012

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