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, &
Personal Information: Gender: M / F
Date of birth: _______________________ Marital Status: ____________________
Religion: _________________________ Profession: _______________________
preferences / food needs: _________________________________
Special Interests: ___________________________________________________
How did you become interested in studying at the Institute of Modern Spanish?
of an emergency, who should we contact?
Relation to self: ____________________________________________________
Telephone (home): ________________ Telephone (work): __________________
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.
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.
do you have with the Spanish language? (i.e. What classes have you
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)
_____ 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:
If your homestay home is not in walking distance of the Institute of Modern Spanish would you prefer to:
_____ 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:
use public transportation or Institute of Modern Spanish van service? (US$5.00/wk) (circle one)
I wish to make alternative housing arrangements (check one):
_______hostel _____ hotel / B & B _____ apartment
_____ family / friends _____ room in guest home
PLEASE CONTACT ME WITH FURTHER INFORMATION
ABOUT ALTERNATIVE HOUSING: YES / NO (circle one)
Local contact information (address & telephone): __________________________________________________
My signature indicates that I have read and understood the Policies & Conditions and that I agree to abide by said policies & conditions.
Signature ______________________________________ Date _________________________
Signature of parent or guardian if applicant is under the age of 18 _______________________________________ Date _________________________Deposit Payment:
Pay Deposti with Credit Card: I, ___________________________ (print your name), give the Institute of Modern Spanish permission to charge my Visa / MasterCard (circle one) in the amount of US$________________ 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):
City ______________________ State ____________ Zip _______________
Telephone Number (______) ___________________