Personal information
* Last name:
* Middle name:
* First name:
* Student ID Number:
(From your university)
* Gender:
F
M
* Date of Birth:
* Citizenship:
Contacts
* E-mail:
Alternative email:
Phone (Country, Code, #):
Cellular Phone (Country, Code, #):
Current mailing address
Street and #:
City:
State:
Zip:
Country:
List two relatives to contact in case of an emergency
Relative 1
Name:
Relationship:
Phone (Country, Code, #):
E-mail:
Relative 2
Name:
Relationship:
Phone (Country, Code, #):
E-mail:
Education Background
Please select your university
College/University presently attending:
INDEPENDENT STUDENT
AASU
BUTLER UNIVERSITY
CSUCI
CSULB
COLUMBIA
LEE
LOYOLA
MORGAN
MSCD
SHSU
TAMU
SDSU
TAMU COMMERCE
TX STATE
UCLA
UofH
UofSD
UofW TACOMA
UofW SEATTLE
UTSA
WNMU
SFSU
INDIANA STATE
UNIVERSITY OF TAMPA
UH GENERAL PROGRAM
UH SPECIAL PROGRAM
UH VISP
UNIVERSITY OF TAMPA
OTHER (SPECIFY IN COMMENTS)
Occupation:
Major and minor:
Native language:
Knowledge of other language(s):
Motivation to learn Spanish:
Pleasure College credits Work requirement Other
Spanish level (6 = most proficient):
1 2 3 4 5 6
Do you intend to transfer credits?:
No Yes
How many? (number of credits):
Which classes? (course number):
(i.e. SPAN 101)
Do you intend to transfer CEU's?:
No Yes
Program of your interest
When are you planning to come?:
Jan '10
Feb '10
Mar '10
Apr '10
May '10
Jun '10
Jul '10
Aug '10
Sep '10
Oct '10
Nov '10
Dec '10
Other (specify in comments)
Desired size program:
Group
Semiprivate
One on One
Program of your interest?:
College immersion
Professional seminar
Children / teen camp
Travel-study program
Internship
Online course
Other (specify in comments)
Length of stay (# of weeks)
1 week
2 weeks
3 weeks
4 weeks
5 weeks
6 weeks
7 week
8 weeks
9 weeks
10 weeks
11 weeks
12 weeks
Semester
Year
Other (specify in comments)
Comments:
How did you learn about this program, please specify (web, friend, teacher,etc.):
Health information
Are you presently taking any medication?
No
Yes
If yes, please explain:
Allergies?:
No
Yes, cats
Yes, dogs
Yes, food
Yes, pollen
Yes, other (specify)
If other allergies, please explain:
Do you smoke?:
No
Yes
Please list any additional information concerning medical conditions or physical disabilities that we should be aware of:
Accommodations/travel and others
Desired accommodations:
Host Family
Nearby Suites
Other
If host family chosen, desired room occupancy?
Double
Single
Triple
If you have a roomate in mind write his/her name:
Arrival date to accommodations:
Last night of accommodations:
Do you need a private chauffeur to pick you up at Mexico City's airport ( $75 Dlls. one way only)? (the return arrange it directly at the school)
No
Yes
If you don't have your flight information, please proceed with the registration. Send your flight info when you have it at info@kukulcan.com.mx
Airline:
Flight number:
Date and time arrival to Mexico City:
Hobbies and interests:
Are you vegetarian?
No
Yes
May Kukulcan release your name and address to actual and/or potential students?
No
Yes
Are you sending simultaneously to this registration form your $150 US deposit fee?
No
Yes
Is this deposit fee sent via wire transfer or paypal?
wire transfer
paypal
Type the security code below:
7852
I am ready to send the information
All data requested is voluntary and will be used to support affirmative action efforts. It will not be used as a basis for admission or in a discriminatory manner.