Institute of Modern Spanish (http://www.modernspanish.com)
Spanish language and Mexican culture studies in Mérida, Yucatán, México
2008-2009 Registration Form

Please PRINT Registration Form. Complete and sign the Registration Form. U.S. Fax number: (775) 213-0406
Mail with non-refundable US$100.00 deposit (applicable toward total program cost) or deposit payment form to:
Institute of Modern Spanish
5802 Bob Bullock (Loop 20)
Building C1 #18-108
Laredo, TX 78041

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: ___________________________________________________
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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.

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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.

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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)

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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)

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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 (______) ___________________