Registration form. Educational tours in Spain. Learn Spanish in Spain

Instructions:

Complete the following application and you will then be asked to pay a deposit of $1000. This deposit is non-refundable.

Ask a teacher who knows you well to complete and return the online recommendation form as you will see in the email we are going to send to you.

1. Student Information and Program Selection

Last Name:	exactly as it will appear on passport
First Name:	exactly as it will appear on passport
Birth Date:
Grade:
Current Spanish Class and teacher (if taking Spanish):
Citizenship if not U.S.
Name of the current school:
Have you been abroad before? (Please list years, countries and time spent):
Email:
Telephone:
Select your Spanish learning program:

2. Parent Information

I live with:

Mother info:

Last Name:
First Name:
Address:
City:
State:
ZIP Code:
Home phone:
Cellular phone:
Work phone:
Fax number:
Email:

Father info:

Last Name:
First Name:
Address:
City:
State:
ZIP Code:
Home phone:
Cellular phone:
Work phone:
Fax number:
Email:

Other person info:

Relationship with you:
Last Name:
First Name:
Address:
City:
State:
ZIP Code:
Home phone:
Cellular phone:
Work phone:
Fax number:
Email:

Whom should we contact first in case of emergency?

3. Special needs

Please describe any special dietary or medical needs the student has (allergies, medications, etc.). Please indicate if the student is currently being treated for any medical, emotional or psychological conditions, or has been treated within the last year for any such condition

4. Statement

In the space below, please describe briefly why you would like to participate in the 2010 A Different Spain Summer Study in Spain Program.

5. Other questions

Please indicate if you have a preferred roommate:

Security Code:

Please write down the following letters as you see in the image:

General conditions agreement:

Yes, I have read and I agree to the 2010 Summer Study Program's General Conditions

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