SANT`ANNA INSTITUTE APPLICATION FORM

SANT’ANNA INSTITUTE APPLICATION FORM
GOLDEN KEY SUMMER 2016 PROGRAM
DATES OF THE PROGRAM:
May 29 – June 13, 2016
APPLICATION CHECKLIST:
 Completed Application Form
 Copy of your unexpired, signed passport
Please send all application materials to [email protected] or via fax at (0039)
081.532.41.40
PERSONAL INFORMATION
Last Name
First Name
 Female Male
Current University/College
Occupation
Country of Citizenship
First Language
Date of Birth (mm/dd/yy)
Passport Number
City/State of Birth
Country of Birth
Permanent Address:
_
_
_
_
(Street)
(Apartment/Unit number)
City _
Country
State_ _
_
_
ZIP Code
_
_
Email
Phone/Fax__
_
_
_
Mobile phone
Sant’Anna Institue - Sorrento Lingue s.r.l
Via Marina Grande, 16 – 80067 Sorrento (Na) – Italy - Tel +39.081.807.5599 – Fax +39.081532.4140
www.santannainstitute.com – [email protected]
P.Iva 07631160012
Allergies (Please state here if you suffer any allergy):_____________________________________________________
Health issues to be communicated:
Are you currently under any medical treatment?:
EMERGENCY CONTACT
Parent/Guardian Name
Relationship
Home Phone
Cell Phone
Email Address_
Street
City
Apartment/Unit
State
ZIP Code
Country_
PRIVACY POLICY
Sant’Anna is registered to hold your personal data under the Italian data protection law. This information
will be used for administrative purposes and will not be given to any third party. I authorize the use of my
personal information by Sant’Anna Institute, in accordance with Italian Law D. Lgs. 196/03 on privacy.
ITALIAN LANGUAGE PROFICIENCY
Select the appropriate level (no knowledge is required):

Beginner
Lower Intermediate
Intermediate
Upper Intermediate
Advanced
List the course title and level of your most recent Italian language course._____________________________
How many semesters of Italian language have you completed?____________________________________
Would you like to participate to the Rome section of the trip? ___________________
Sant’Anna Institue - Sorrento Lingue s.r.l
Via Marina Grande, 16 – 80067 Sorrento (Na) – Italy - Tel +39.081.807.5599 – Fax +39.081532.4140
www.santannainstitute.com – [email protected]annainstitute.com
P.Iva 07631160012
CANCELLATION POLICY
If an official cancellation notice is received by Sant’Anna:
-Sant’Anna Institute-Sorrento Lingue SRL will refund 30% of the total amount if the program is cancelled up to
45 days prior to the start of the program. For later cancellations no refunds will be due. If the program is
cancelled due to force majeur (e.g. war, terrorism, state department warning), 50% of the total amount will be
refunded.
- Should a student cancel 2 weeks before the program start, no refund will be due.
After classes start, no refund will be due to students who do not attend or who withdraw from Sant’Anna.
Fees are not transferable to other persons.
Students will receive the refund minus the cost of any transfer fees.
I HAVE READ, UNDERSTOOD, AND WILL ABIDE BY THE ABOVE SANT’ANNA POLICIES AND
REGULATIONS. MY SIGNATURE BELOW ALSO ATTESTS TO THE FACT THAT I HAVE BEEN MADE
AWARE OF THE INFORMATION REGARDING:
Student signature

Date
I appoint the Sant’Anna Institute to forward, in my name and on my behalf, my payment of the accommodation
and expenses as established and chosen in this application form.
I understand that:
 I will enter my apartment/accommodation ONLY at the Check-in date, and I must leave the assigned
apartment no later than 12:30 pm on Check-out day;
 Sant’Anna reserves the right to expel from the assigned accommodation any student whose behavior
does not conform with civilized standards of behavior;
I HAVE READ, UNDERSTOOD, AND WILL ABIDE BY ALL OF THE SANT’ANNA INSTITUTE POLICIES,
RULES, AND REGULATIONS ON THIS FORM.
Student signature

Date
Print Student Name
Sant’Anna Institue - Sorrento Lingue s.r.l
Via Marina Grande, 16 – 80067 Sorrento (Na) – Italy - Tel +39.081.807.5599 – Fax +39.081532.4140
www.santannainstitute.com – [email protected]
P.Iva 07631160012