U N I V E R S I T Y of H O U S T O N

L A N G U A G E and C U L T U R E C E N T E R
INTENSIVE ENGLISH COURSE APPLICATION FORM

I. Calendar III. Visa Information

For which semester are you applying? A. For all students:
1. After you study intensive English, in what subject do you
II. Applicant Information
plan to major?
1. Applicant’s name:

2. After language training, which is the first level of education

Last (Family)
if any, you plan to obtain in the United States?

First Middle
3. After language training, do you plan to study at the University of
2. Sex: Houston?

3. Native Language:
B. For students outside the United States only:
4. Country issuing passport: 1. Will you enter the U.S. on a student visa (F-1)?

5. City and country of birth: If no, what type of visa will you have?

2. Do you need an F-2 visa for your spouse and/or children?

6. U.S. permanent resident:

Spouse’s name Sex Date of birth
7. U.S. citizen:
Spouse’s Country of Birth Spouse’s Country of Citizenship
8. Date of birth:

9. Date of high school graduation: 1st child’s name Sex Date of birth

10. Address and telephone number in your country: 1st child’s Country of Birth 1st child’s Country of Citizenship

2nd child’s name Sex Date of birth

Number & Street (Line 1)

2nd child’s Country of Birth 2nd child’s Country of Citizenship

Number & Street (Line 2)

3rd child’s name Sex Date of birth

City State/Province

3rd child’s Country of Birth 3rd child’s Country of Citizenship

Country Postal
C. For students inside the United States only:
1. What type of visa do you currently have?
Telephone Fax

2. Are you changing to F-1 Visa?

11. Address in the United States, if any, care of: 3. Are you transferring from another school in the U.S.?
If yes, what is the name of the school?

First Middle Last (Family)

IV. Miscellaneous:
1. How did you hear about us?
Number & Street (Line 1)

2. Email addresses:
Number & Street (Line 2)
Email 1:

City State Zip Code Email 2:

Telephone
 https://class-fmkr-11.class.uh.edu/lccapp_22.php

Applicant's name: Record ID: Date and Time:

Language and Culture Center - Intensive English Program

Online Application Form - Part 2

Section 2.1 Statement of Financial Support

You must submit proof of adequate financial support for study in the
United States before you can be issued an I-20. Acceptable proof is
1) an I-134 Affidavit of Support or a letter signed by your sponsor
verifying sponsorship, or the sponsor's signature after the statement
below, and 2) proof of the sponsor's financial resources, for
example, a letter from the sponsor's bank or the sponsor's tax
records.

If you are over 21 and have the funds to support yourself, you do not
need a sponsor, but you must submit proof of your financial
resources.

This is to certify that i will assume full financial responsibility

for a minimum of $20,000.00 U.S. per year (2 terms of study and 1
year of living expenses) for the support of the student named in this
application while he/she is attending the University of Houston
Language and Culture Center.
_____________________________________________________________________________
Student signature Date

_____________________________________________________________________________
Sponsor signature Date

Section 2.2 Sponsor Information

If you will be sponsored, please fill in the following information about your sponsor:

Name: _______________________________________________________________________
First Name Middle Name Last Name

Address: ____________________________________________________________________
Street and Number Apt.#

_____________________________________________________________________________
City State/Province Postal Code

_____________________________________________________________________________
Country Telephone Number

Sponsor's relationship to student: __________________________________________

Section 2.3 Application Fee

The $100.00 U.S. application fee must accompany this Statement of

Financial Support and accompanying documents. The application fee is

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 https://class-fmkr-11.class.uh.edu/lccapp_22.php

valid for one year from its date of receipt in the Language and
Culture Center office. After that date, you will need to submit new
financial support documents and repay the application fee if you wish
additional I-20s.

The application fee is nonrefundable.

Section 2.4 Mailing Instructions

The following documents should be mailed as soon as possible to

arrive in Houston before the application deadline: (Check application
deadline)

Part 2 of the Online Application Form (signed and complete)

Application fee of $100 (USD) by a check drawn on a U.S. bank or
money order payable to the "University of Houston"
Payment must be done by check, money order, or wire transfer.
Checks and money orders must be drawn on a U.S. bank
Personal checks must include the name, address, U.S. Driver
License number, and date of birth of the person writing the
check
When paying by wire transfer, we need a copy of the receipt
in order to process the application
We do NOT accept cash or credit cards
Proof of financial support of at least $20,000 USD, per student
Copy of your transcript or diploma (high school or greater) with
a certified English translation
English translation of your transcript or diploma
Copy of the identification page of your passport
Permission for Emergency Treatment Form
Required for all students under the age of 18
Must be signed by the student's parent or legal guardian
Proof of Bacterial Meningitis Immunization Compliance Form
Any copies of medical documents issued in any language other
than English must come with a certified English translation
Please refer to the Meningitis FAQ for any question
If you are a transferring student from another school in the US,
please fill out the LCC Transfer Form.

Make check or money order payable Please mail to:

to the "University of Houston"
Language and Culture Center
Online Application
116 Roy Cullen Building
Houston, Texas 77204-3014
USA

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Please be aware that students enrolled in the English language program who are under the age of eighteen
must have a parental medical release form on file in order to participate in the program.

Please read the following PERMISSION FOR EMERGENCY TREATMENT form.

Sign and return the permission form to:

Language and Culture Center

University of Houston
116 Roy Cullen Building
Houston, TX, 77204

Email: lcc@uh.edu
Tel: (713) 743-3030
Fax:(713) 743-3029

PERMISSION FOR EMERGENCY TREATMENT

On rare occasions an emergency requiring hospitalization and/or surgery develops. Since minors may

not, as a rule, be administered an anesthetic or be operated upon without written consent of the parent or

legal guardian, we request that a parent or guardian sign this statement. This is to prevent a dangerous

delay in case an emergency does occur and we are unable to contact parents or guardians.

In the event of a medical emergency involving my son/daughter/ward,____________________________,

Student’s Name
born_______________ I hereby authorize the hospital or acting physician to administer whatever medical
Student’s Birthdate
treatment is deemed necessary, including the administration of an anesthetic and surgery.

________________________ __________________________________________
Date Signature of Parent or Legal Guardian

__________________________________________
Printed Name of Parent or Legal Guardian