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Application for Admission

- Step 1 of 3

Personal Information

Name *

First

Last

Email *

Confirm Email

Phone *

Date of Birth *//

Gender *

Male
Female

How did you hear about us. *

If Friend/Family or Other, please specify. *

If you are referred by an agency, please state the name of the company.

Do you have or need an F-1 visa? *

An F-1 visa is a non-immigrant visa for those wishing to study in the U.S.

What is your status? *

Initial (I want to go to the US. I need an F-1 visa.)
COS (I am in the US. I want to change my visa to F-1.)
Transfer (I have an F-1 visa. I want to transfer.)

Country of Birth *

City of Birth *

Country of Citizenship *

Where are you staying? *

In the US
Outside the US

U.S. Address (Your home address in the U.S.) *

Address Line 1

Address Line 2

City

State

Zip Code

Foreign Address (Your home address outside the US.) *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Mailing Address (Complete if different from the above.)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Do you have dependents you want to add on your Form I-20? *

Dependents are spouses and/or unmarried minor children. Children 21 years of age or older are not eligible to enter as the dependent of an F-1 student.

If Yes, how many dependents? *

One
Two
Three
Four or more

Dependent 1

Relationship *

Spouse
Child

Gender *

Male
Female

Name *

First

Last

Date of Birth *//

Country of Birth *

City of Birth *

Country of Citizenship *

Dependent 2

Relationship *

Spouse
Child

Gender *

Male
Female

Name *

First

Last

Date of Birth *//

Country of Birth *

City of Birth *

Country of Citizenship *

Dependent 3

Relationship *

Spouse
Child

Gender *

Male
Female

Name *

First

Last

Date of Birth *//

Country of Birth *

City of Birth *

Country of Citizenship *

Additional Dependents

Please list additional dependents in the same format. *

Program

When did you obtain your F-1 visa? *

Before March 9, 2020
After March 9, 2020

Morning Course Requirement *

I agree to take face-to-face (offline) courses offered between 9:00am and 1:30pm, and maintain my F-1 status. I understand that USCIS mandates “students who enrolled after March 9, 2020, must adhere to SEVP’s existing regulations regarding online learning, found at 8 C.F.R. § 214.2(f)(6).” In other words, “no online or distance learning classes may count toward an ESL student's full course of study requirement.”

Which type of courses? *

Online Courses (Poly Live)
Offline Courses (Face-to-face)

Please select the center where your records should be kept.

Which School Location? *

POLY Languages at Irvine
POLY Languages at Los Angeles

Which Program? *

General Courses
Private/Group Lessons

For General Courses, students must be 17+ years of age. For Private/Group Lessons, students must be 12+ years of age.

PL Checkboxe *

For private lessons, one of our staff members will contact you and arrange the actual start date. The start date you select will be used only as a reference point.

When would you like to start? *

How many weeks do you plan to study? *

Our terms are 4 weeks long.

How many hours per week? *

For pricing, refer to Tuition and Fees.

How many hours per week? *

For pricing, refer to Tuition and Fees.

Housing Services

Do you want us to arrange your housing? *

POLY provides a homestay arrangement service for new students. If you want your housing arranged in a timely manner, you must request the service at least 30 days prior to your desired move-in date.
There is a $200 security deposit. The security deposit and a 30-day rent is due 20 days prior to the student’s scheduled move-in date.The monthly rental rate and the payment policy may vary slightly depending on a host family. The monthly rental rates below are only estimates.

With meals (Breakfast & dinner): $1,500/month
Without meals: $1,200/month

Do you have any health problems, allergies, or concerns you would like us to know?

The information you state the above will be disclosed, if deemed necessary, to the applicable parties related to your housing.

Private/Group Lessons

How many lessons? *

Each lesson is 80 minutes long.

How many students? *

There is a charge of $60 per student per term (4 weeks).

Which days? *

Monday
Tuesday
Wednesday
Thursday
Friday

Check the day(s) you are available for the lessons. Please make it flexible so that you have more teachers to choose from.

Which start-time? *

What time of the day(s) is the best for you to start your lessons? The start time must be between 8:00 am - 8:00 pm, Pacific Time.

Note/Comment

Tuition and Fess

Application Fee (F-1) *

$150 (non-refundable)

Application Fee *

Mailing and Handling Fee

$80 (non-refundable)

Student Visa Assistance Service (F-1 Initial)

$250 (non-refundable)

The Student Visa Assistance Service includes the following:
* We assist you in in completing the SEVIS Form I-901.
* We assist you in completing the Visa Application (Form DS-160).
* We assist you in scheduling and preparing for your F-1 Visa Interview.
* We can send you another acceptance packet free of charge if your visa is rejected.

Total Due *

$ 0.00

Once you're accepted, we will assist you with all aspects of the admission process.

Assisted by (Optional)

Stated the name of the advisor who assisted you in completing this form.

Stripe Credit Card *

Card

Name on Card

Acknowledgement and Agreement *

I acknowledge that I have access to the School Catalog, and I have read, understood, and I agree to all the terms and conditions of this Application for Admission and the School Catalog. Furthermore, I agree to accept full responsibility for all my expenses while attending POLY Languages Institute and for my actions while participating in excursions or any other activities. I agree to assume all risks of harm arising from such participation. In case of illness or injury, permission is granted to an appropriate medical center to undergo examination or treatment. I further authorize POLY Languages Institute to release my records to my agency, guardian, sponsor, and to any colleges or universities to which I apply.

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