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 - July 1, 20193 week - September 30, 2019 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.