Name
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First Name
Last Name
Gender
*
M
F
Other
Prefer not to say
Date of Birth
*
MM
DD
YYYY
Ocupation
*
Country that Issued Your Passport
*
Passport Number
Expiration Date
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Telephone
*
Country
(###)
###
####
Email
*
For which English School cycle are you applying?
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How did you hear about our program?
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1. At what level do you consider your Spanish speaking skills? (select one)
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2. Do you plan on participating in the afternoon political-cultural program? If so, what are your interests for this program?
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3. Do you plan on taking Spanish classes? If so, what dates do you plan on attending?
*
4. Why do you want to participate in this program? What do you hope to get out of the experience?
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1. Do you want to stay with a host family?
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2. Do you need any of the following housing options?
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3. What are your smoking preferences?
*
4. Do you have any dietary restrictions? (check all that apply)
Food allergy (specify):
Other (specify):
5. Do you have any allergies to medicine?
*
If yes, specify:
6. Do you have any health problems/restrictions? (incl. asthma, migraines, etc.)
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a. If yes, in what way are you managing it? (i.e. inhaler, insulin, etc)
b. If yes, what additional accommodations can we provide to help?
8. Are you currently taking any medication?
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If yes, specify
1. Do you have any special skills (technical, health care, teaching ESL, computers, etc.)?
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2. Have you been active in community, international solidarity, or political organizations or parties? Please describe.
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3. Have you traveled to Latin America or elsewhere? If so, where, when, and what did you do?
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4. Do you have any experience with teaching English, or with popular or community education?
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5. Why do you want to participate in this program? What do you hope to get out of the experience?
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6. Please share with us your views on Central American issues.
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