Online Registration

Please complete the application form and we will assess your request once it is received.

If you are an Education Agent completing this form, please note that we must have a signed Agency Agreement in place before we can accept your student.

By completing this form, you agree to our Terms and Conditions.

Personal Information
Title (e.g. Mr., Mrs.):
First Name *
Family Name *
Gender Male Female
Birth Date *
Nationality *
Primary Language *
Where did you hear about East Coast Language College? *
If you selected Other please specify
If you selected Agent please complete the following questions:
Agent Company Name
Name of Agent
 
Address
Street and Street Number *
City *
Postal Code *
Country *
 
Contact Details
Telephone Number *
Student Email Address *
Agent Email Address
Fax
 
Emergency Contact in Canada
Contact Name
Relationship
Telephone Number
 
Program Information
I would like to register for the following program *
If you selected Other please specify
I would like to register the following number of weeks *
If you selected Other please specify
I would like to start on *
If you selected Other please specify
 
University College Pathway Only
Do you plan to attend a partner University or College? * Yes No
 
Homestay Information
Are you under 19 years of age? * Yes No
If you are under 19 years of age, in order to be accepted to ECLC you must either stay with an ECLC Host Family or provide guardianship/custodianship information.
Accommodation Options
Would you like our Accommodation Coordinator to help you find other accommodation in Halifax? *

Yes No
 
Payment Information
I want to make payment of the $160 Application Fee by *

I want to pay school tuition
 fees by *
Health insurance is mandatory and will be added to your invoice if you cannot provide the following information.
I have already purchased health insurance * Yes No
Health Insurance Company
Policy Number
Policy start date
Policy end date
Special Instructions
 
Conditions and Verification
By checking this box you agree to East Coast Language College terms and conditions *
I Agree (Click Here to View)

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