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Please fill out the form in English.

Student Information

Gender *
Male Female
First Name *
Last Name *
Date of Birth *
Grade*
Junior Level
5th Grade (10-11yrs)
6th Grade (11-12yrs)
7th Grade (12-13yrs)
8th Grade (13-14yrs)

Senior Level
9th Grade (14-15yrs)
10th Grade (15-16yrs)
11th Grade (16-17yrs)
12th Grade (17-18yrs)
＊During participation in the summer camp
Student Email *
Confirm Student Email *
Phone Country Code - City Code - Number
Nationality *
Address
City
State/Province
Zip/Postal
Country
Language Spoken *

Emergency Contact

Emergency Contact Full Name *
Emergency Contact Relationship *
Emergency Contact Email *
Emergency Contact Phone * Country Code - City Code - Number

Parent or Legal Guardian Information

Name of the Parent or Guardian *
Parent or Guardian Daytime Phone
Parent or Guardian Home Phone Country Code - City Code - Number
Parent or Guardian Mobile Phone *
Parent or Guardian Email *

Summer Camp Information

Accomodation *
UCLA Residence Self-arranged
Program Starting Date *
Program Level *
Number of Weeks *

Extra Day In Residence: $541 per day

*Program, accomodation, and 3 meals included

*With a maximum of 3 extra days

Extended Stay
Number of days ($541/day)
Number of extra nights BEFORE camp start date
Number of extra nights AFTER camp end date
Irregular Pick-up($170)/Drop-off($150)
Arrival NOT Sunday
Departure NOT on Saturday
Unaccompanied Minor Service ($140 / round trip)
Yes
No

*Irregular pick-up or drop-off: $170 (pick-up) and $150 (drop-off). If both are irregular, total $320 (with or without Unaccompanied Minor Service).

・Special Pick-Up:
Flight Arrival between 17:31-20:30 (outside of the regular shuttle schedule) ($170). Pick-up is guaranteed for flights arriving by 20:30.
・Special Drop Off:
Flight Departure between 15:00-17:00 (outside of the regular shuttle schedule) ($150). Please arrange a flight schedule to depart LAX no later than 17:00.
Processing Fee (Enrollment Fee)
$156 ($150 + Credit Card Fee: $6) *

Application Regulations

Leave the course:

It is possible to leave the course at any time during the term. When departing from the course, in order to display the intention of the students themselves, it is necessary to submit a written statement stating that. In addition, schools may offer to withdraw from the course, such as when inappropriate behavior, attendance rate and grades do not satisfy standards as students.

Right to termination:

You have the right to cancel this enrollment and obtain a refund of charges paid for attendance more than 45 days prior to the scheduled arrival date. 'Cancellation' is defined as any voluntary change in enrollment or request for a refund before the actual enrollment.

Refund Policy:

・If the student’s application for entry into the U.S. is denied by Homeland Security at Los Angeles International Airport (LAX), MLI-Annex will refund the program fee minus the $150 registration fee and the $250 cancellation fee. The student must provide a letter of rejection from the port of entry from LAX to receive the refund.
・If the student withdraws before June 1st during the program year, MLI- Annex will refund the program fee minus the $150 registration fee and the $250 cancellation fee. If cancellation occurs before any payment is made, the $150 registration fee and $250 cancellation fee are still payable.
・If the student withdraws after June 1st of the program year, or if the student is dismissed from the program after the start date, no refunds will be given.

Payment of Refunds Owed to Students

Refund payments owed to a student shall be paid to the student’s booking agency within forty-five (45) days of MLI-Annex receiving written notification of the withdrawal. All bank fees associated with the payment of a refund are the student’s responsibility.

Written Notice Required

To be considered for a refund, the student must submit a written and signed notice to MLI-Annex of withdrawal from the program. Verbal notices will not be honored.

Signature Section

I have read and understood all of the above and I agree to all these terms and conditions.
Parent's Name*
Date

For Agency Use Only

Agency Name Agency Representative Name Agency Representative Email Sales Representative

Our Missions

At MLI-ANNEX, our mission is to provide an enriching learning environment by hosting our youth summer camp at UCLA for international students. We offer students the unique opportunity to live in UCLA dorms, ensuring they have an unforgettable experience that goes beyond what they can achieve studying English in their own country. Students will receive communicative English lessons and engage in a variety of activities to practice their English. Additionally, students will visit many attractive spots in Los Angeles.

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