REGISTRATION FORM

1. PERSONAL INFORMATION Note: Asterisk * denoted fields are required.
Name:*
Date & Place of birth:

Male: Female:

Marital status:

Address:
Telephone number:* (work)
Fax:
Email:*

(home)(Include fax if you need confirmation of enrollment)
Profession:
How did you hear about the C.R.L.A.?cCRlanguage-academy
What languages do you speak?
Have you received Spanish classes before? Yes No
If yes, where? For how long?
In what level of Spanish do you consider to be at this moment?

IMPORTANT

PROGRAM YOU ARE ENROLLING FOR (hour/day, homestay,etc.)?

DATES YOU WILL BE AT THE ACADEMY
DATE, TIME and No. OF ARRIVAL FLIGHT

Do you want to be picked up at the airport? Yes No

2. LODGING
What type of lodging and family do you prefer?
Private room Shared room
Quiet atmosphere Social atmosphere
Children Pets
Smoking non-smoking
Vegetarian or non-vegetarian food
Other preferences
Do you have allergies or other relevant health problems? (Specify)

  If you have problems sending this form, please fill in the appropriate information, print and fax or forward email.

NOTE: The information provided will be used to make the best possible match between student and host family. Although we try to meet as many student's desires as posssible, we do not require that the family or the Academy provide everthing that the student has checked off.

What do you hope to gain from this experience?

[Use if faxing this document]

Student signature___________________________ Date

PERSON TO NOTIFY IN CASE OF EMERGENCY
Name & relation to student

Address

Telephone (home)
(office)

Please or