2020package information - central pacific college...is to gradually improve the students’...

Information Package2020

VisionTo transform people’s lives through English language learning for self-realization.

MissionTo provide high-quality English language teaching for multicultural communication among all learners.

Central Pacific College (CPC) assists learners of English by focusing on can-do goals, meeting one-on-

one with instructors, and using a personalized learning plan. CPC strives to provide opportunities to

develop linguistic and cultural competence necessary to function within a multicultural environment in

Hawai’i and in the rest of the English-speaking world.

CPC is committed to providing high levels of education by:

• Providing diverse academic, extra-curricular and accommodation options that optimize the students’

study abroad experience. CPC’s friendly and professional staff strive to assist students with all of their

needs.

• Encouraging students to extend their learning beyond the classroom. CPC offers a wide variety of

academic workshops that promote interest in topics and skills not explored in everyday classes. Topics

such as Survival English, Introduction to TOEIC and TOEFL are offered every term.

• Supporting students who wish to pursue higher education in the United States. CPC has transfer

agreements to enroll at fifteen universities and colleges across the US: Adelphi University, American

University, Auburn University, Auburn University at Montgomery, Florida International University,

Kapiolani Community College, Louisiana State University, The University of Central Florida, University

of Dayton, The University of Illinois at Chicago, The University of Kansas, University of Massachusetts,

Massachusetts Boston, The University of the Pacific, University of South Carolina, and the University

of Utah.

1221 Kapiolani Blvd. Suite 740

Honolulu, HI, 96814

Phone: (808) 791-7800

[email protected]

Central Pacific College is located at 1221 Kapiolani Boulevard, a five-minute walk to Ala Moana Shopping Center and Ala Moana Beach. Occupying two suites on the seventh floor of a professional office building, CPC provides students with a comfortable learning environment.

* The schedule is subject to change.**All classes are opened based on a minimum enrollment and are subject to change.

2020SCHEDULE

EPP - English Proficiency Program (Mon - Fri)

STEP - Short-term English Program (Mon - Thu)

MON TUE WED THU FRI

MO

RNIN

GSC

HED

ULE

**

9:00 amto

10:50 am

GrammarUse Class

GrammarUse Class

GrammarUse Class

GrammarUse Class

GrammarUse Classs

Break

11:00 amto

12:50 pm

IntegratedSkills Class





AFT

ERN

OO

NSC

HED

ULE

**

1:00 pmto

2:50 pm

GrammarUse Class

GrammarUse Class

GrammarUse Class

GrammarUse Class

GrammarUse Class

Break

3:00 pmto

4:50 pm






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English Proficiency Program(EPP)The English Proficiency Program (EPP) has been designed to empower students to take control of their learning progress by using can-do goals and by using a personalized learning plan. The overall goal is to gradually improve the students’ communicative fluency and academic skills in order to become successful English speakers. The program is comprised of eight different levels (i.e., True Beginner through Proficiency). Most EPP students have a student visa and are committed to the study of English full-time (twenty hours a week plus additional hours of preparation at home).

Short-Term English Program (STEP)The Short-Term English Program (STEP) is for students who do not have an F-1 student visa and who study for sixteen hours per week, typically four hours per day, Monday through Thursday. Classes are offered in the morning and afternoon, depending on enrollment. Similar in structure to the EPP program, it allows students to experience and participate in a comprehensive program (i.e., True Beginner through Proficiency) for up to twelve weeks.

TOEFL®︎ programThis program prepares students to take the TOEFL® exam through comprehensive review and practice of the skills that are commonly tested on the exam.

TOEIC®︎ programThis program prepares students to take the TOEIC® exam through comprehensive review and practice of the skills that are commonly tested on the exam.

Club Keiki Program(Seasonal & For kids only: 6-14yrs old )Club Keiki is a seasonal children’s program that is available in the spring (for one week) and in the summer (for a maximum of five weeks). Students are engaged in cultural activities for four hours in the morning and two and a half hours of English classes in the afternoon with a half hour break for lunch in between. The total number of hours it takes to complete the Club Keiki program in the spring is 35 hours and 175 hours in the summer.

SCHOOL | OFFERED PROGRAMS

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The Club Keiki program provides students with the opportunity to participate in specific Hawaiian activities in the morning while engaging in afternoon English classes that improve students’ receptive skills.

The English curriculum assists students to familiarize themselves with English, and Hawaiian and American culture!

-> Minimum enrollment: 1 week; Maximum enrollment: 5 weeks

-> Average student to teacher ratio: 10:1

-> Program fees include transportation, admission fees, lunch, snack, Club Keiki t-shirt, and tuition. Well-trained and qualified activity leaders will accompany students during the field trip to ensure their safety and well-being. There will be at least one activity leader to accompany every four or five children.

-> Complimentary Club Keiki t-shirts will be provided to all students upon enrollment in the program.

* The information above is subject to change.

From July 20, 2020to August 21, 2020(5 weeks)

SPRING

SUMMER

From March 23, 2020to March 27, 2020(1 week)

8:30 - 3:45pm(daily)

6 - 14 years old

• After completing the application process, we will send a detailed schedule.

• Transportation via school bus or mini van will be provided for those activities that are far from CPC.

• For activities located near CPC, students and activity leaders will travel on foot.

DATES:

TIME:

AGES:

From May 4, 2020to May 8, 2020(1 week)

EARLY SUMMER

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SCHOOL CALENDAR2020

SU M T W TH F SA SU M T W TH F SA SU M T W TH F SA SU M T W TH F SA

12/8 12/9 10 11 12 13 14 1/12 1/13 14 15 16 17 18 2/9 2/10 11 12 13 14 15 3/8 3/9 10 11 12 13 14

15 16 17 18 19 20 21 19 1/20 21 22 23 24 25 16 2/17 18 19 20 21 22 15 16 17 18 19 20 21

22 23 12/24 25 26 27 28 26 27 28 29 30 31 2/1 23 24 25 26 27 28 29 22 23 24 25 3/26 27 28

29 30 31 1/1 2 3 4 2 3 4 5 6 7 8 3/1 2 3 4 5 6 7 29 30 31 4/1 2 4/3 4

5 6 7 8 9 10 11


4/5 4/6 7 8 9 4/10 11 5/3 5/4 5 6 7 8 9 31 6/1 2 3 4 5 6 7/5 7/6 7 8 9 10 11

12 13 14 15 16 17 18 10 11 12 13 14 15 16 7 8 9 10 6/11 12 13 12 13 14 15 16 17 18

19 20 21 22 23 24 25 17 18 19 20 21 22 23 14 15 16 17 18 19 20 19 20 21 22 23 24 25

26 27 28 29 30 5/1 2 24 5/25 26 27 28 29 30 21 22 23 24 25 26 27 26 27 28 29 30 7/31 8/1

28 6/29 30 7/1 2 3 4


8/2 8/3 4 5 6 7 8 8/30 8/31 9/1 2 3 4 5 9/27 9/28 29 30 10/1 2 3 10/25 10/26 27 28 29 30 31

9 10 11 12 13 14 15 6 9/7 8 9 10 11 12 4 5 6 7 8 9 10 11/1 2 11/3 4 5 6 7

16 17 18 19 20 8/21 22 13 14 15 16 17 18 19 11 10/12 13 14 15 16 17 8 9 10 11/11 12 13 14

23 24 25 26 27 28 29 20 21 22 23 24 25 26 18 19 20 21 22 23 24 15 16 17 18 19 11/20 21


22 11/23 24 25 11/26 11/27 28 27 12/28 29 30 31 1/1 2 1/24 1/25 26 27 28 29 30 2/21 2/22 23 24 25 26 27

29 30 12/1 2 3 4 5 3 4 5 6 7 8 9 31 2/1 2 3 4 5 6 28 3/1 2 3 4 5 6

6 7 8 9 10 11 12 10 11 12 13 14 15 16 7 8 9 10 11 12 13 7 8 9 10 11 12 13

13 14 15 16 17 18 19 17 1/18 19 20 21 22 23 14 2/15 16 17 18 19 20 14 15 16 17 18 3/19 20

20 12/21 22 23 24 25 26

School Holidays Graduation

December 2019 / January 2020 January / February February / March March / April

Central Pacific College2020 Annual Calendar

Term A 2019-2020Module 1 Module 2 Module 3 Module 4

August August / September September / October October / November

Term B 2020Module 1 Module 2 Module 3 Module 4

April / May May June / July July / August

Term C 2020Module 1 Module 2 Module 3 Module 4

1221 Kapiolani Blvd., Suite 740 Honolulu, HI 96814 Ph: (808) 791-7800 Fax: (808) [email protected] www.cpchawaii.edu

New enrollment period for STEP:Part time students(Any Monday except for holidays)

New enrollment period for EPP: Full time(F1) students

2020Jan 1 - New Year’s DayJan 20- Dr. Martin Luther King, Jr. Day Feb 17 - President’s Day Mar 26 - Prince Jonah Kuhio DayApr 10 - Good Friday

May 25 - Memorial Day Jun 11 - King Kamehameha Day Jun 29 - Jul 3 - Summer VacationJul 3 - Independence Day Aug 21 - Statehood Day

Sep 7 - Labor DayOct 12 - Columbus DaysNov 3 - General Election DayNov 11 - Veterans' DayNov 26-27 - ThanksgivingDec 21 - 25 - Winter Vacation

Term A 2020-2021

Module 1 Module 2 Module 3 Module 4

November 2020 / December 2020 December 2020 / January 2021 January / February February / March

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BOOKING PROCESS

1. F1 VISA STUDENT (EPP PROGRAM)

1. Registration form filled out online at

https://cpchawaii.edu/admission/

2. Student Information form filled out online at

https://cpchawaii.edu/form-application/

3. We will require you to e-mail ([email protected]) or

fax the following documents:

• A copy of your passport (photo page)

• A copy of your or your bank statement.

The minimum balance of your bank statement will need to be over $20,532.

The bank statement must be in English and submitted no later than 3 months

prior to the date of the I-20 issuance. $20,352 is the total cost of living

expenses and tuition fees in order to study at CPC. Not having sufficient

funds in your bank statement may result in being ineligible to obtain student

status for a full year. They may instead study in the program for the length of

time that their funds make them eligible for.

4. When the payment for the express mailing fee of $100

is confirmed, we will issue an I-20 and an acceptance letter

will be mailed to you via FedEx.

Please fill in the following form to pay for the express

mailing fee https://cpchawaii.edu/form-card/

5. Apply for a student visa at the U.S. Embassy in your

country.

6. Notify CPC of what the results of the interview are.

7. Payment for tuition and textbooks.

8. Travel to Hawaii!

The following link will show what you can expect from your

first day https://cpchawaii.edu/yourwelcomeday/

2. NON F1 VISA STUDENT (STEP PROGRAM)






4. Travel to Hawaii!


first day.

https://cpchawaii.edu/yourwelcomeday/

3. KIDS PROGRAM STUDENT (CLUB KEIKI PROGRAM)

1. Kids Program Registration form filled out online at

https://cpchawaii.edu/form-keiki/

4. TRANSFER STUDENT





3. We will require you to e-mail ([email protected]) or

fax the following documents:

• A copy of your passport (photo page)

• A copy of your student visa

• A copy of your current I-20

• Signed CPC transfer form (You need to personally take

the form to your current school and have the form signed

by your current school DSO.)

*Please note that a student MUST submit all documents

to CPC in order for CPC to issue I-20.

• A copy of your or your bank statement.

The minimum balance of your bank statement will need to be over $20,532.

The bank statement must be in English and submitted no later than 3 months

prior to the date of the I-20 issuance. $20,352 is the total cost of living

expenses and tuition fees in order to study at CPC. Not having sufficient

funds in your bank statement may result in being ineligible to obtain student

status for a full year. They may instead study in the program for the length of

time that their funds make them eligible for.

4. When the payment for the express mailing fee of $100

is confirmed, we will issue an I-20 and an acceptance letter

will be mailed to you via FedEx.

Please fill in the following form to pay for the express

mailing fee https://cpchawaii.edu/form-card/


6. Please come to CPC


first day https://cpchawaii.edu/yourwelcomeday/

*If you require accommodations, please contact Student

Service America (SSA) at:

Tel: +1(808) 542-9114 / E-mail: [email protected]

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REFUND POLICY

1. 2020 CPC REFUND POLICY

Cancellation Before Classes Begin or Non-showIf a student cancels before attending classes and have not entered the United States, CPC will refund all monies paid less non-refundable charges (i.e., registration fee, I-20 mailing fee, accommodation processing fee if applicable) of up to $500.

Refunds will be paid either within 45 calendar days of the student’s cancellation date or within 45 calendar daysof the first scheduled day of class, whichever is earlier. The cancellation date is determined by the student’s notification to withdraw.

Students Denied Visa/EntryA student denied a student visa or entry into the United States will be given a full refund of all monies paid less non-refundable charges (i.e., registration fee, I-20 mailing fee, accommodation processing fee if applicable) of up to $500. Refunds will be made within 45 calendar days from the date of notification of visa or entry denial.

Withdrawal or Termination After Classes BeginSee “REFUNDs (DOES NOT INCLUDE NONREFUNDABLE CHARGES)” below.

Students who are terminated because of violations of CPC rules/policies (including attendance) will receive a prorated refund. The refund will be calculated based on the last date of attendance.

REFUNDs (DOES NOT INCLUDE NON-REFUNDABLE CHARGES) - If the last date of attendance occurs at any point in the first four weeks of the period of enrollment, CPC retains the charges applicable to the first four weeks.

-If the last date of attendance occurs after the first four weeks but before or at the mid-point of the period of enrollment, CPC retains a prorated amount of tuition. -If the last date of attendance occurs after the midpoint CPC retains all of the charges for that period.

2. 2020 STUDENT SERVICE AMERICA REFUND POLICY* The housing services are offered by Student Service America for CPC students.

BEFORE A STUDENT MOVES IN:You have the right to withdraw your housing application at any time. A withdrawal can take place by written notice provided by you to Student Service America Inc.

STUDENT’S RIGHT TO CANCEL:You have the right to cancel your housing application form and obtain a refund of charges if notice of cancellation is made 30 days before your scheduled move in date.

You must indicate your request to cancel and obtain a refund by submitting a letter to the address listed on your housing application form.

REFUND POLICYYou shall be refunded 100% of the amount paid to Student Service America Inc. if notice of cancellation is made more than 30 days before your scheduled move-in date. An applicant must agree that he/ she will forfeit the remaining balance of any rent payment (up to 30 days), as well as incur a cancellation fee of $270/$300, if he/ she cancels the housing tenancy less than 30 days before the occupancy date as listed above. If the student moves out after moving in, no refund will be issued unless a replacement is found. All refunds, as determined above, will be paid within 30 days after the notice of refund has been accepted, according to our cancellation or move out policy.

AIRPORT PICKUPYou shall be refunded 100% of the amount paid for Student Service America Inc. If notice of cancellation is made more than 72 hours before your scheduled airport pickup. If a student cancels after the above cancellation deadline, no refund will be issued.

If your booking was facilitated by an authorized our overseas agent, the processing of any applicable refund may be governed by the contractual agreement between Student Service America Inc. and the agent. You are advised to consult with your agent prior to entering into this enrollment agreement should you have any questions.

8 8

2020

99

PRE ENROLLMENT APPLICATION

If you have any questions regarding this application form, please feel free to email or call CPC.

Enrollment Dates – Please check the date in 2020 you wish to start: F-1 Applicants: Please indicate which date you would like to begin below. □ Dec. 9, 2019

□ Jan. 13, 2020

□ Feb. 10

□ Mar. 9

□ Apr. 6

□ May 4

□ June 1

□ July 6

□ Aug. 3

□ Aug. 31

□ Sept. 28

□ Oct. 26

□ Nov. 23

□ Dec. 28

Length of study (in weeks): Non F-1 Applicants: Please indicate which date you would like to begin your studies on the right. Mondays only (Tuesday if the Monday is a holiday)

Non F-1 Only __________/__________/___2020__ Month Day Year

Length of study (in weeks) :

Student Information Family Name (Surname):

First (Given) Name: Middle Name:

Country of Birth: Date of Birth (MM/DD/YYYY):

Country of Citizenship: Sex: □ Male □ Female

City/Province of Birth: Email:

Home Country Street Address:

City: State:

Postal Code: Country:

Phone: Mobile Phone:

Address in Hawaii (if known):

Emergency Contact Name: Relationship:

Emergency Contact Telephone Number:

Emergency Contact Email:

10 10

Are you a transfer student? □ Yes □ No If “Yes,” please indicate your current school name: If “Yes,” please indicate your last attending date at this school:

Current Level of English: □ Beginner □ High -Beginner □ Low Intermediate □ Intermediate □ Low Advanced □ Advanced How did you hear about CPC? Please indicate name and source (e.g. Agent, website, internet, Etc.)

Program Information □ EPP (English Proficiency Program) – 20 hours/week □ STEP (Short Term English Program) – 16 hours/week □ TOEIC ® – 20 hours/week □ TOEFL ® – 20 hours/week □ Club Keiki (Summer Kids Program)

Do you need an I-20? □ Yes □ No

In addition to the fees below, all I-20 applications must be accompanied by a financial statement verifying your ability to meet expenses. (Estimated expenses per school year: $20,352.00) If “Yes,” please indicate how you would like us to deliver your I-20: □ Mail □ Pick up (by friend or relative in the US) If you need to come together with your families(F2), Number of dependent: ________ Their Country of Citizenship:_________________ Their Country of Birth :_________________ Required Fees: ✓ Registration Fee (STEP/Club Keiki $100 or EPP $150, non-refundable) ✓ Express Mail (EPP $100, non-refundable) ✓ Textbook fee (2 textbooks)

□ Purchase New ($100-$120) Rental for students that only apply for 1-3 weeks □ 1 week ($20) □ 2 weeks ($40) □ 3 weeks ($60)

Accommodation □ Homestay □ Condominium Residence (Shared condo) : ( )Private ( )Shared ( )Quad □ Condominium □ None Transportation □ One way □ Round □ None I have read and understood that this is a pre-enrollment application, that certain fees are non-refundable, as noted, and that my enrollment will not be completed until I obtain a visa (if required) and execute an enrollment agreement in person at CPC. Signature:_____________________________________ Date (month/day/year):__________________________

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Student Information: Last Name (Family name): _________________________ First (Given) Name:_________________________ Nationality:________________ Gender: Male Female Visa: F-1 Other Date of Birth: _____________________(MM/DD/YYYY)

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66 Arrival Information:

Arrival Date: _______________(MM/DD/YYYY) Arrival Time:______________ Airline:______________ Flight#:____________

Housing Options: (select the housing option)

Transportation Service: Airport Pick-up $100 -All applicants must use our airport pickup service. Guaranteed pickup is 7AM to 8PM (flight arrival time) and/or accommodation check-in time is 7AM to 9PM.) A Airport Drop-off $100 - Guaranteed pickup time (accommodation) is 7AM to 7PM. The accommodation check-out time is 12AM. *Any other times are not guaranteed, S.S.A. may pickup from 8PM to 11PM with a $35 late pickup fee.

Preferences for students choosing a Homestay Family (We will do our best to meet your preferences; however, we cannot guar-antee that we will meet all of them. For best results, please submit this application at least 30 days before you plan to move in. I prefer a family with children: Yes No Most important for me (Please choose one): Time to talk with the family Location. I want to be close to the school. Other:

Other: If you have any physical or mental conditions, you may list them here so that we can accommodate your needs. Please note: by list-ing any information here, you agree that we may share this information with third parties as we see fit.__________________ _________________________________________________________________________________________________________

If you have any other requests or would like to provide any other information, please do so here:____________________________

99

By signing below, I hereby certify that the facts set forth above are complete and true to the best of my knowledge. I agree that my application will not be pro-cessed until S.S.A. has received $270 from me for placement in a condominium residence or $300 for placement in a homestay. [If a student rejects our airport pickup service, an additional $30 will be charged.] I agree that I will forfeit the remaining balance of any rent payment (up to 30 days), as well as include a cancellation fee of $270/$300, if I cancel the housing tenancy less than 30 days before the occupancy date as listed above. I agree that a cancellation fee of $100 will be charged if I cancel the airport pickup service or change my flight less than 72 hours before the scheduled arrival time. If I postpone my arrival date from the date listed above, I understand that I will be charged a new place-ment fee or a rental fee. I also understand that I need to pay a maintenance fee and a security deposit on my arrival. The maintenance fee is non-refundable. The secu-rity deposit is refundable after moving out, as long as there is no damage to the room and property. A Refund Request Form must be filled out. This application is for the periodic rental agreement, and the period of my stay is specified above. I agree to move out on the date above. I have the option to extend my stay only if there is availability. I understand that if I am enrolled with Central Pacific College and cancel my enrollment, my SSA accommodation will be terminated. Termination of accommodation will occur within the grace period. I understand that falsification of any information on this form will result in forfeiture of the placement fee without refund. I have read and agree to these terms. Print name:_________________________________ Signature:________________________________ Date:____________________________

Personal Information:

Smoker: Yes No

Note: No homestay families allow smoking; you must smoke outside.

Allergies: Do you have any allergies? Yes No If yes, please list:____________________________________

Emergency Contact Information:

Name: _______________________ Relationship: ___________ Telephone: __________________ E-mail: ___________________

Move In Date: _____/_____/______ mm/ dd /yyyy

Move Out Date:

_____/_____/_____ mm/ dd / yyyy

Student Service America 1221 Kapiolani Blvd., Suite 740 Honolulu, HI 96814 USA Phone: 808-542-9114 Fax: 808–791-7804 Email: [email protected]

Agent Name:

For office use only:

Application Received: _____/_____/______ Program Start Date: _____/_____/_______

Package Options: Dance (Studio: )

( _________ week (s) or Number of Lessons: ) Surf (Studio: )

( _________ week (s) or Number of Lessons: ) Yoga (Studio: )

( _________ week (s) or Number of Lessons: ) Scuba Diving:

( _________ week (s) or Number of Lessons: )

Homestay *Placement Fee $300 Security Deposit $200 (Refundable) Homestay (Private, 2 meals/day) $460/week $1,400/4 weeks *Additional 5% will be charged applied at homestay for age under 17 and over 55. **Guardian Rates: $105/week (age of under 17)

Condominium Residence (Moana House) *Placement Fee $270 Security Deposit $200 (Refundable) Maintenance Fee $25/week, $100/4 weeks or more ___Private, No meals $518/week, $1,904/4 weeks ___Shared-2, No meals $362/week, $1,242/4 weeks ___Quad-4, No meals $259/week, $890/4 weeks *Guardian Rates: $50/week (age of under 17)

1100

2020 HOUSING APPLICATION

STUDENT SERVICE AMERICA

12 12

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Student Information: Last Name (Family name): _________________________ First (Given) Name:_________________________ Nationality:________________ Gender: Male Female Visa: F-1 Other Date of Birth: _____________________(MM/DD/YYYY)

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66 Arrival Information:

Arrival Date: _______________(MM/DD/YYYY) Arrival Time:______________ Airline:______________ Flight#:____________

Housing Options: (select the housing option)

Transportation Service: Airport Pick-up $100 -All applicants must use our airport pickup service. Guaranteed pickup is 7AM to 8PM (flight arrival time) and/or accommodation check-in time is 7AM to 9PM.) A Airport Drop-off $100 - Guaranteed pickup time (accommodation) is 7AM to 7PM. The accommodation check-out time is 12AM. *Any other times are not guaranteed, S.S.A. may pickup from 8PM to 11PM with a $35 late pickup fee.

Preferences for students choosing a Homestay Family (We will do our best to meet your preferences; however, we cannot guar-antee that we will meet all of them. For best results, please submit this application at least 30 days before you plan to move in. I prefer a family with children: Yes No Most important for me (Please choose one): Time to talk with the family Location. I want to be close to the school. Other:

Other: If you have any physical or mental conditions, you may list them here so that we can accommodate your needs. Please note: by list-ing any information here, you agree that we may share this information with third parties as we see fit.__________________ _________________________________________________________________________________________________________

If you have any other requests or would like to provide any other information, please do so here:____________________________

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By signing below, I hereby certify that the facts set forth above are complete and true to the best of my knowledge. I agree that my application will not be pro-cessed until S.S.A. has received $270 from me for placement in a condominium residence or $300 for placement in a homestay. [If a student rejects our airport pickup service, an additional $30 will be charged.] I agree that I will forfeit the remaining balance of any rent payment (up to 30 days), as well as include a cancellation fee of $270/$300, if I cancel the housing tenancy less than 30 days before the occupancy date as listed above. I agree that a cancellation fee of $100 will be charged if I cancel the airport pickup service or change my flight less than 72 hours before the scheduled arrival time. If I postpone my arrival date from the date listed above, I understand that I will be charged a new place-ment fee or a rental fee. I also understand that I need to pay a maintenance fee and a security deposit on my arrival. The maintenance fee is non-refundable. The secu-rity deposit is refundable after moving out, as long as there is no damage to the room and property. A Refund Request Form must be filled out. This application is for the periodic rental agreement, and the period of my stay is specified above. I agree to move out on the date above. I have the option to extend my stay only if there is availability. I understand that if I am enrolled with Central Pacific College and cancel my enrollment, my SSA accommodation will be terminated. Termination of accommodation will occur within the grace period. I understand that falsification of any information on this form will result in forfeiture of the placement fee without refund. I have read and agree to these terms. Print name:_________________________________ Signature:________________________________ Date:____________________________

Personal Information:

Smoker: Yes No

Note: No homestay families allow smoking; you must smoke outside.

Allergies: Do you have any allergies? Yes No If yes, please list:____________________________________

Emergency Contact Information:

Name: _______________________ Relationship: ___________ Telephone: __________________ E-mail: ___________________

Move In Date: _____/_____/______ mm/ dd /yyyy

Move Out Date:

_____/_____/_____ mm/ dd / yyyy

Student Service America 1221 Kapiolani Blvd., Suite 740 Honolulu, HI 96814 USA Phone: 808-542-9114 Fax: 808–791-7804 Email: [email protected]

Agent Name:

For office use only:

Application Received: _____/_____/______ Program Start Date: _____/_____/_______

Package Options: Dance (Studio: )

( _________ week (s) or Number of Lessons: ) Surf (Studio: )

( _________ week (s) or Number of Lessons: ) Yoga (Studio: )

( _________ week (s) or Number of Lessons: ) Scuba Diving:

( _________ week (s) or Number of Lessons: )

Homestay *Placement Fee $300 Security Deposit $200 (Refundable) Homestay (Private, 2 meals/day) $460/week $1,400/4 weeks *Additional 5% will be charged applied at homestay for age under 17 and over 55. **Guardian Rates: $105/week (age of under 17)

Condominium Residence (Moana House) *Placement Fee $270 Security Deposit $200 (Refundable) Maintenance Fee $25/week, $100/4 weeks or more ___Private, No meals $518/week, $1,904/4 weeks ___Shared-2, No meals $362/week, $1,242/4 weeks ___Quad-4, No meals $259/week, $890/4 weeks *Guardian Rates: $50/week (age of under 17)

1100

2020 HOUSING APPLICATION

STUDENT SERVICE AMERICA

Central Pacific College

1221 Kapiolani Blvd. Suite 740Honolulu, Hawaii 96814

Tel: 1-808-791-7800Fax: 1-808-791-7804

E-mail: [email protected]: www.cpchawaii.edu

1313

Student Name: Last First

Card Type: VISA Mastercard JCB Amex

Card Number:

Expiration Date (MM/YY): /

Security Code:

Name on the card:Last First

Billing Address:

City

State / Province

Zip / Postal code

Country

Amount authorized to charge: US $

I herebery authorize Student Service America to charge the above amount to my credit card.

Card Holder's Signature: Date:

Student Service America1221 Kapiolani Blvd. Suite 740

Honolulu, HI 96814 Tel: 808-542-9114 Fax: 808-791-7804

14 14

Central Pacific College1221 Kapiolani Blvd. Suite 740

Honolulu, HI, 96814Phone: (808)[email protected]

www.cpchawaii.edu

2020package information - central pacific college...is to gradually improve the students’...

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