Online Enrolment Form Where did you hear about us?Please select...Search EngineBrochureAgentFriendOtherPlease specify:Agent Employee Name:* Agency Company Name:Agent Email Address:* Phone Number:*Have you studied at Evakona before?*YesNoYour Contact Details (Please use English) Name:* First Last Email Address:* Student's Email Address:* Home Address:* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone Number:*Personal Information (Please use English) Date of Birth:* Date Format: DD slash MM slash YYYY Gender:*MaleFemaleNationality:*Occupation/Job:Passport Number:*Do you currently hold a New Zealand Visa?YesNoWhat type of Visa will you hold in New Zealand?Please select...Visitor/TouristStudentWorking HolidayOtherWhat type of Visa do you currently hold?Please select...Visitor/TouristStudentWorking HolidayOtherOther Visa Type:What is the expiry date of this Visa? Date Format: DD slash MM slash YYYY Emergency Contact (Please use English) Please provide us with an emergency contact.This could be an agent, a family member, or friend.Use AGENT details as your emergency contact? Use AGENT details as your emergency contact? Name:* Relationship:*Address:*Phone Number:*Email:* Course Information (Please use English) Which campus do you wish to study at?WhitiangaThamesWhich course do you require?Please select...General English - Full-time 23 hours/weekGeneral English - Part-timeExam Preparation TOEIC - 23 hours/week group lessonsExam Preparation TOEIC - 19 hours/week group lessonsHigh School Preparation- Full-time 23 hours/week + activityOtherOther Courses (if required):Would you like to include Friday activities with your course?YesNoHow many weeks do you wish to study?Course Start: Date Format: DD slash MM slash YYYY Course End: Date Format: DD slash MM slash YYYY Your English Level:Please select...BeginnerElementary (TOEIC 10-200)Pre-Intermediate (TOEIC 200-399)Intermediate (TOEIC 400-699)Upper Intermediate (TOEIC 700-899)Advanced (TOEIC 900+)TOEIC/IELTS Score:Accommodation (Please use English) Do you require us to arrange accommodation?*HomestayBackpackers/MotelApartmentNot RequiredFirst Night: Date Format: DD slash MM slash YYYY Last Night: Date Format: DD slash MM slash YYYY Number of weeks/nights:Do you smoke?YesNoWould you prefer a non-smoking family?YesNoNo preferenceWould you like to stay with a family with children?YesNoNo preferenceWould you like to stay with a family with pets?Are dogs OK?YesNoNo preferenceAre cats OK?YesNoNo preferenceDo you have any mental or physical health issues and/or allergies?*Yes (please specify)NoPlease specify any health issues...Is there any food you cannot eat?*Yes (please specify)NoPlease specify any foods you cannot eat...Do you have any special circumstances that would make living with a homestay family difficult for you?Yes (please specify)NoPlease specify any special circumstances...What are your hobbies/interests?Transport to/from Auckland Airport (Please use English) Do you require transport from Auckland to your school on ARRIVAL?Yes from Auckland AirportYes from Auckland CityNoUndecided (To be advised)Arrival Date: Date Format: DD slash MM slash YYYY Arrival Time: : HH MM AM PM Flight Number:Do you require transport from your school to Auckland on DEPARTURE?Yes to Auckland AirportYes to Auckland CityNoUndecided (To be advised)Departure Date: Date Format: DD slash MM slash YYYY Departure Time: : HH MM AM PM Flight Number:Do you require Check-In Assistance during departure? Yes Health and Medical Information (Please use English) Do you want Evakona to arrange insurance for you?*YesNo, I have my own insurancePlease advise your insurance policy details:Insurance Dates:Do you have any pre-existing medical conditions?Yes (please specify)NoPlease specify any pre-existing medical conditions...Declaration (Please use English) Is the student under 18 years old?YesNoThe following is to be completed by a parent or legal guardian if the student is under 18.If the student is under 18, please provide legal guardian details:*Does the student require Unaccompanied Minor Service during flights? Yes I give Evakona Education permission to use photos/videos of me for school promotional material and on social media.*YesNoI have read, understand and agree to the Evakona Education Terms & Conditions*I have read, understand and agree to the Evakona Education Terms & Conditions. * Yes
