Spanish Immersion in Latin America Application Form

WORKING ABROAD Spanish Immersion in Latin America

WORKING ABROAD

Spanish Immersion in Latin America Application Form Which country would you like to go to?

Costa Rica

Guatemala

Last Name:

Peru

First Name:

Mailing Address: STREET ADDRESS

CITY

STATE

Email:

ZIP/POSTAL CODE

COUNTRY

Telephone:

Date of Birth:

Gender:

Male

Female

Citizenship:

MM/DD/YYYY

Current Occupation: Knowledge of Spanish:

Beginner

Intermediate

Advanced

Fluent

Desired Start Date* (must be a Monday): Course Selection:

Small Group (four hours/day)

Private (four hours/day)

Six-hour combo (four hours group + two hours private/day Number of weeks: Private Room Upgrade:

Yes

No Please note that private rooms are subject to availability.

Extra nights/special instructions (may be indicated later):

Please list the names of any one else with whom you will be participating:

Do you smoke?

Yes

No

Host family with children?

Yes

No

No Preference

Host family with pets?

Yes

No

No Preference

 MEDICAL INFORMATION Medical conditions:

Special dietary requirements or allergies (e.g. vegetarian):

 EMERGENCY CONTACT DETAILS Name:

Relationship to you:

Phone Number:

Email:

Signature of Applicant:

Date: MM/DD/YYYY

WA-PA315-1114

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