Apply: Coomeva Vacation Program Applicant Information First Name: Last Name: Gender: ---MaleFemale Date of Birth: Native Language: Country of Nationality: E-mail Address: Canada Address and Contact Information Street Address: City, Province, Postal Code : Phone Number: Fax Number: Country Address and Contact Information Street Address: City, Province, Postal Code : Country: Phone Number: Fax Number: Application Information Please select desired program and start date: ---3 week January 6, 20203 week March 30, 20204 week March 30, 20203 week June 29, 20204 week June 29, 20203 week September 28, 20204 week September 28, 2020 If you are travelling with a friend or relative, and would like to reside in the same homestay, please tell us this person's name: Do you smoke? ---YesNo Are you comfortable with pet(s)? ---Yes, I am comfortable with catsYes, I am comfortable with dogsYes, I am comfortable with any pet(s)No, I am not comfortable with any pet(s). Do you have any allergies? ---YesNo If yes, please explain: If you would like to provide us with other information, please use the space below: Payment Information A CAD$100 non-refundable deposit is required to process your application and issue a letter of acceptance. Click “Submit now!” to submit your application. You will then be redirected to our secured online payment page to make your $100 deposit. Students will also be registered for Insurance at an additional cost of $60.00 fir this program. * London Language Institute will be in contact with you within 3 business days. ** Please contact our office if you require an original letter of acceptance couriered to you. *** Fees for this service vary and we can provide you with this service if required.