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?* Yes No Your 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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone Number:*Personal Information (Please use English) Date of Birth:* DD slash MM slash YYYY Gender:* Male Female Nationality:* Occupation/Job: Passport Number:* Do you currently hold a New Zealand Visa? Yes No What 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? 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? Yes No How many weeks do you wish to study?Course Start: DD slash MM slash YYYY Course End: 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?* Homestay Backpackers/Motel Apartment Not Required First Night: DD slash MM slash YYYY Last Night: DD slash MM slash YYYY Number of weeks/nights: Do you smoke? Yes No Would you prefer a non-smoking family? Yes No No preference Would you like to stay with a family with children? Yes No No preference Would you like to stay with a family with pets?Are dogs OK? Yes No No preference Are cats OK? Yes No No preference Do you have any mental or physical health issues and/or allergies?* Yes (please specify) No Please specify any health issues...Is there any food you cannot eat?* Yes (please specify) No Please 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) No Please 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 Airport Yes from Auckland City No Undecided (To be advised) Arrival Date: DD slash MM slash YYYY Arrival Time: : Hours Minutes AM PM AM/PM Flight Number: Do you require transport from your school to Auckland on DEPARTURE? Yes to Auckland Airport Yes to Auckland City No Undecided (To be advised) Departure Date: DD slash MM slash YYYY Departure Time: : Hours Minutes AM PM 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?* Yes No, I have my own insurance Please advise your insurance policy details:Insurance Dates: Do you have any pre-existing medical conditions? Yes (please specify) No Please specify any pre-existing medical conditions...Declaration (Please use English) Is the student under 18 years old? Yes No The 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.* Yes No I have read, understand and agree to the Evakona Education Terms & Conditions*I have read, understand and agree to the Evakona Education Terms & Conditions. * Yes Δ