English School in Mississauga | ESL Near Square One

STEP 1: PERSONAL INFORMATION

First Name *

Last Name *

Nickname

Gender

Phone

Email

Birthday (YYYY-MM-DD)

Nationality

Mother Tongue

Address in Home Country

Mississauga Address (if known)

STEP 2: PROGRAM DETAILS

Course

Start Date (YYYY-MM-DD)

# of Weeks

Homestay

Insurance Own insurance: bring certificate on first day. GuardMe: $2.50/day.

Visa Type

Estimated Total Auto-calculated

STEP 3: REFERRAL & EMERGENCY CONTACT

How did you hear about Homeland?

Emergency Contact Name

Relationship

Emergency Phone

Emergency Email

STEP 4: AUTO-CALCULATED FEES

Semi-Intensive: $295/week for 1-3 weeks, $280/week for 4+ weeks
Intensive: $365/week for 1-3 weeks, $350/week for 4+ weeks
IELTS/CELPIP: $155/week • Application fee: $125 (non-refundable)
Textbook fee: $75 per level (each level is 10 weeks) • GuardMe: $2.50/day

Tuition
Application Fee
Textbook Fee
Insurance Fee
Total

STEP 5: AGENT INFORMATION (IF APPLICABLE)

Agent Name

Contact Information

Agency Name

Contact Person

Agency Address

STEP 6: CONSENT & SIGNATURES

I confirm that all information provided is correct

I agree to the fees and terms & conditions

Student Signature

Date (YYYY-MM-DD)

Parent / Guardian Signature