(Fields marked with * must be filled in)

GENERAL INFORMATION

First Name*________________________________________

Last Name* ________________________________________

Street Address* __________________________________________________________

City* _____________________________________________

State* _____________________________________________

Country* __________________________________________

Zip Code* _____________________

Home Phone* ______________________________________

Work Phone _______________________________________

Fax ___________________________

E-Mail* __________________________________________

Date of Birth ___________________

Sex (circle one):       male        female

Marital status (circle one):        single                   married

Occupation  ________________________________________

Nationality* _______________________________________

Emergency Contact Name & Phone Number

____________________________________________________________________

____________________________________________________________________

How did you hear about us?

____________________________________________________________________

SPANISH LANGUAGE LEVEL

(This is just to give us an idea of your level, but your placement will be determined by an exam given upon your arrival.)

Estimated Language Level* (circle one):      Beginning     Intermediate     Advanced

Number of years you’ve studied Spanish* _____________________________________

Comments on your Spanish level:

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

What other languages do you speak?

____________________________________________________________________

PROGRAM INFORMATION---Immersion Program

(Note: Courses begin on Mondays and end on Fridays.  If you are participating in the Homestay Program, your accommodation will begin on a Sunday and end on a Sunday unless you are signing up for the Design-Your-Own Immersion Program)

Course Start Date*  Day:___________          Month:_____________     Year:_________

Course End Date*  Day:___________           Month:_____________     Year:_________

Number of weeks of study* (circle):   1 week      2 weeks      3 weeks     4 weeks Other: _____________

Reason for choosing school: ____________________________________________________________________

____________________________________________________________________

Expectations:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

PROGRAM INFORMATION---Design-Your-Own Immersion Program

Course Start Date*  Day:___________          Month:_____________     Year:_________

Course End Date*  Day:___________           Month:_____________     Year:_________

Number of days of program*: ___________________

Number of hours of classes you would like per day*: _______________

Reason for choosing school:

____________________________________________________________________

____________________________________________________________________

Expectations:

 ____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

HOMESTAY INFORMATION

Stay with a family?* (circle):        yes             no

If your answer is no, please disregard questions in "Homestay" section.

If your answer is yes, please answer the following questions*

Room Type (circle one):  Private Room       Shared Room           

Are you traveling with a companion? (circle one):      yes       no     

If so…

Will you be sharing a bed with him or her?     yes       no

Will you be sharing a bedroom with him or her?     yes       no

Companion’s Name: ______________________________________________________

Do you smoke? (circle):       yes       no

If staying with a companion, does your companion smoke?(circle):       yes       no

Do you prefer a non-smoking household? (circle):    yes       no

DIETARY INFORMATION FOR STUDENTS STAYING WITH A FAMILY & SHARING MEALS

Which meals will you be sharing with a family? (circle one):

    No Meals                Breakfast only                       Breakfast, lunch, dinner

Do you have any dietary restrictions? (circle):       yes       no

If so, what are they? (list): ____________________________________________________________________

____________________________________________________________________

HOTEL ACCOMMODATIONS

If you choose not to stay with a host family, we can arrange a hotel room for you.

Would you like us to make hotel reservations at hotel Hotel Posada Tonala (Mid-range Rooms $40 one person, $50 two persons)?     yes       no

Room type (circle one):   one double bed       two double beds

Number of people in room:     one person       two persons      other:______________

Do you prefer a non-smoking room? (circle):    yes       no

Total Amount of Fees for Courses (check one):

(This is your estimate only)

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