Young Registration Form Year-Round Young Adult Programs (Ages 16 to 18) Step 1 of 2 50% Student InformationGender M F X Email Name First Last Date of Birth MM slash DD slash YYYY Phone NumberAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Nationality Emergency Contact Mother Tongue Emergency Contact Phone:Passport Are you currently in Canada? Yes No Agent InformationAgency Contact Person Agent Email Program InformationProgram Intensity Start Date: MM slash DD slash YYYY Weeks of study Course Focus General English CELPIP Preparation Business English TOEFL Preparation IELTS Preparation University Pathway Program Other Pathway College InformationCollege/University name Program name I have applied to a college Yes No Start Date MM slash DD slash YYYY I will use the DEAC Pathway service to get a conditional LOA from a college or university Yes No The agency is doing the application process directly with the college/university Yes No Untitled Airport TransferArrival Date MM slash DD slash YYYY Flight Information Airport Pick-up Yes No Departure Date MM slash DD slash YYYY Flight Information Airport Pick-up Yes No Accommodation (14-day Self-Quarantine)Accommodation Single Homestay Single Homesta Specify Residence Special Requests or Preferences Accommodation (Post-Quarantine)Accommodation Single Homestay Twin Homestay Length in weeks Specify Residence Special Requests or Preferences Parents/Guardians InformationParent/Guardian 1Name First Last Date of Birth MM slash DD slash YYYY Home Address PhoneParent/Guardian 2Name First Last Date of Birth MM slash DD slash YYYY Home Address PhoneDo you require a custodian declaration? Yes No Medical InformationDo you have medical insurance ? Yes No Policy Number If “No”, would you like to book insurance through DEAC? Yes No Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Do you have any allergies? Yes No List Allergies Do you have any medical issues? Yes No List Medical Issues Do you have any physical disabilities? Yes No List Physical Disabilities Do you have any food restrictions? Yes No List Food Restrictions Are you allergic to pets? Yes No Specify which pet(s) Do you smoke? Yes No CAPTCHA