Gender:
*
First Name:
*
Last Name:
*
E-mail Address:
*
Retype Email address::
*
Age:
*
Birthday:
*
Example:(21/12/1970) / (Day, Month, Year)
City:
*
State/Province:
*
Country:
*
Zip/Postal Code:
*
Phone:
*
Fax:
Arrival Date in Cuernavaca:
*
Example:(21/12/1970) / (Day, Month, Year)
Date to Begin Classes?
*
Example:(21/12/1970) / (Day, Month, Year)
Approximate length of studies? (number)
*
Anticipated departure Date from Cuernavaca:
*
(21/12/1970) / (Day, Month, Year)
Citizenship:
*
Occupation:
*
Employer:
*
What living arrangements would you like?
Select One.
Mexican Homestay Family
School Dormitories (limited-register early)
Apartment or house
Hotel
No arrangement necessary.
If staying with a homestay family or in the dorms, what meal plan would you like?
Select One.
No meals
Prepare own meals (dorms)
One meal only in dorms (Kitchen facilites available)
One meal:Mexican homestay
Two meals:Mexican homestay only
Homestay family or dormitory room type:
Select One.
Private Room with Private Bath
Private Room with Shared Bath
Shared Room with Private Bath
Shared Room with Shared Bath.
Do you smoke?
Select One.
No
Yes but only outside.
Yes
Will you want airport pick-up service (8am-12 midnight)? There is an extra charge of $100 one way for this service. If you will be requiring pick-up between 10pm and 8am there is an additional $10 charge. If you are coming with other students, please contact us (Info@ExperienciaSpanish.com) for disounted pricing information.
Select One.
Yes
No
Flight arrival information (airline, flight number, time of arrival). This helps for airport pick-up as well as informing homestays of approximate arrival time at their home.
Why do you want to learn Spanish? How will you use it after your studies?
Have you ever studied Spanish before (Please specify)?
Will you want small group classes or individual classes?
Select One.
Small group (no more than 5 students)
Individual
What would you like to discuss during the conversation period or hear about during the lectures? Select as many of the following that interest you:
Any other suggestions for topics or themes?
How did you hear about EXPERIENCIA?
Select One.
Internet web search
Link from another website
Friend or colleague
Informational flyer at your school/agency
Other
Emergency Contacts: (Name, Relationship to you, Address, Phone, Email)
Any other information that you think would be helpful to us in arranging your stay (medical situation, allergies to animals, dietary needs, i.e. vegetarian, diabetes, etc)?
Would you like to be included on our mailing list for program updates and special promotions regarding EXPERIENCIA, Centro Cultural?
Select One.
Yes
No
WAIVER OF LIABILITY AND HOLD HARMLESS STATEMENT Travel and especially travel to developing countries presents certain risks and uncertainties. I take full responsibility for accepting these inherent risks. I hold harmless and release from any liability, legal and otherwise, EXPERIENCIA, Centro Cultural, from anything that may occur.
Agreement to Release and Waiver Terms (Select from menu)
I Agree to terms of Waiver
I do not agree
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