Institute of Modern Spanish (http://www.modernspanish.com)
Spanish language and Mexican culture studies in Mérida, Yucatán, México
2009-2010 Registration Form

Please PRINT Registration Form. Complete and sign the Registration Form. U.S. / Canada Fax number: (877) 463-7432
Mail with non-refundable US$100.00 deposit (applicable toward total program cost) or deposit payment form to:
C/O Gerald Ott
4124 NE Hillcrest Ct.
Ankeny
, IA 50021

Last name: ________________________________________________________

First name: ________________________________________________________

Street Address: ____________________________________________________

City, State, & Zip: ___________________________________________________

Telephone: ________________________________________________________

E-mail: ___________________________________________________________

Personal Information: Gender: M / F

Date of birth: _______________________ Marital Status: ____________________

Religion: _________________________ Profession: _______________________

Allergies: _________________________________________________________

Special eating preferences / food needs: _________________________________

Special Interests: ___________________________________________________
_
How did you become interested in studying at the Institute of Modern Spanish?

_________________________________________________________________

In case of an emergency, who should we contact?

Name: ___________________________________________________________

Relation to self: ____________________________________________________

Address: _________________________________________________________

Telephone (home): ________________ Telephone (work): __________________

E-mail: ___________________________________________________________


Arrival information (to Merida's airport):

I want to be picked up at the airport: Yes / No (circle one) (US$10.00 charge)

Arrival date: _________ Arrival time: _________ AM / PM

Airline: _____________ Flight Number: _______

Description of alternative transportation arrangements (i.e. bus from Cancun, etc.):
_________________________________________________________________

Departure date & time: _______________________________________________

Mexican Family Homestay includes the weekends before and after study at the Institute of Modern Spanish. You are welcome to arrive earlier than Saturday or stay later than Sunday; each additional day of Shared Accommodations is US$20.00; each additional day of Private Accommodations is US$25.00.


School Information:

If you are a student/teacher, what is the name of your school? ________________________________________________

Major (s) ____________________ Grade/Subject ___________________________

Year in School _________________ What are your career plans? ________________________________________________

Do you plan to receive college credit for your Institute of Modern Spanish course work? __________________________

If so, have you had your credit transfer requested preapproved at your home school? ____________________________

Please email list of intended course work.


Language Information:

What experience do you have with the Spanish language? (i.e. What classes have you taken? When?)

______________________________________________________________________________________________________

What is your native language? _________________ Do you speak any other language(s)? ______ If so, which one(s)? ____________________

How would you rank your current Spanish language ability level? (Circle One)

Beginner (You have no formal knowledge of the language. You may know a few set phrases. You do not understand spoken Spanish.)

Elementary (You know many set phrases pertaining to yourself and present situations. You generally understand nontechnical speech when presented clearly.)

Intermediate (You are able to construct meaningful utterances about yourself and present situations. You may also be able to communicate about past and future events. You understand spoken Spanish when presented clearly--mostly in social contexts.)

Advanced (You are able to construct meaningful utterances about present, past, and future. You may also be able to communicate about hypothetical situations. You understand the majority of spoken Spanish when presented clearly in almost all contexts.)



I wish to register for...

Spanish Language & Conversation Instruction:

_____ weeks of private / group / combination (circle one) instruction

for 10 /15 / 20 / 25 / 30 / 40 (circle one) hours per week.

Monday Start Date: _________________


Family Homestay Housing:

_____ weeks of private / private plus / shared (circle one) housing

_____ additional days of private / private plus / shared (circle one)

You can only register for shared housing if you are registering with a roommate.

 

Arrival Date: ______________________

Departure Date: ______________________

I wish to share housing with:   

 __________________________
If your homestay home is not in walking distance of the Institute of Modern Spanish would you prefer to:
use public transportation or Institute of Modern Spanish van service? (US$5.00/wk) (circle one)


I wish to make alternative housing arrangements (check one):

_______hostel _____ hotel / B & B _____ apartment

_____ family / friends _____ room in guest home

PLEASE CONTACT ME WITH FURTHER INFORMATION
ABOUT ALTERNATIVE HOUSING: YES / NO (circle one)
 

Local contact information (address & telephone): __________________________________________________

_________________________________________________________________________________________

My signature indicates that I have read and understood the Policies & Conditions and that I agree to abide by said policies & conditions.

Signature ______________________________________ Date _________________________

Signature of parent or guardian if applicant is under the age of 18  _______________________________________ Date _________________________

Deposit Payment:

I wish to pay my deposit (circle one) online / credit card / electronic check / mail check payment
To pay your deposit via electronic check, please download the registration packet.

Pay Deposti with Credit Card: I, ___________________________ (print your name), give the Institute of Modern Spanish permission to charge my Visa / MasterCard (circle one) in the amount of US$________________ to cover my registration deposit for a _____-week (write number of weeks) study program in Mérida, Mexico. I understand that this form authorizes the Institute of Modern Spanish to charge the US$100.00 deposit to my card upon receipt of this form and that the deposit is non-refundable. The balance will be due on my Monday start date.

Credit Card Number _____________________________________________ Expiration Date _____ / _____

Signature ___________________________________ Date ______________

Street address of card holder including city, state, & zip (billing address):

Street ________________________________________________________

City ______________________ State ____________ Zip _______________

Telephone Number (______) ___________________