Apply for Language Course

Apply Now!

 Within 48 hours of receiving your application, you will receive a secured payment page to place a 20% deposit in order to hold a place on the course location and start date of your choice.  Please read our Terms and Conditions.

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  •  Name *
    First
    Last
     
     
  •  Address *
    Street Address
    Address Line 2
    City
    State / Province / Region
    Zip / Postal Code

    Country  

  • Nationality *
     
  •  Gender *
    Female
    Male
     
  •  Phone Number
     
  •  Email *
     
  •  Alternate Email *
     
  •  Date of Birth *
    MM/
    DD/
    YYYY
     
     
  •  Emergency Contact *
    First
    Last
     
     
  •  Emergency Contact Email *
     
  •  Course Location *
    Santo Domingo, DR
    Sosua, Puerto Plata-DR
     Santiago, DR
     Nicaragua
    Israel
    Toronto, Canada
     
  • Desired Course Start Date *
    MM/
    DD/
    YYYY
     
     
  •  Desired Course Finish Date *
    MM/
    DD/
    YYYY
     
      
  • Language Level *
    No Knowledge
    Beginner
    Intermediate
    Advance
      
  • Accomodation Choice *
      Apartment
    Hotel
    One to One Homestay Option
    I will not need accomodation assistance
     
  • Desired Locations and Length of Stay
  •  Please list desired destinations for study from our available course locations as well as the desired length of time. The minimum stay in any one country must be at least 4 weeks.
  •  Would you like our Language Assistant Program?
  • Yes
     
 Choose a Language Assistant Start Date
MM/
DD/
YYYY
  • Sent form using email /Paypal or  snail mail  it with payment  to “Hineni Media”  here
  • Further Questions or Comments?  here

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