• FIRST NAME*
• LAST NAME*
• DATE OF BIRTH
  • Month January February March April May June July August September October November December
  • Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
  • Year 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
• AGE
  AGE Less than 18 18 to 30 31 to 55 Over 55
• COUNTRY*
• OCCUPATION*
• SEX*
  SEX MALE FEMALE
• CIVIL STATUS
  CIVIL STATUS Single Married
• WORK PHONE*
• HOME PHONE*
• FAX
• EMAIL ADDRESS*
• CONFIRM EMAIL*
• WHAT IS YOUR LEVEL OF SPANISH
  LEVEL OF SPANISH Zero Poor Good Fair Advanced
• DO YOU HAVE A HEALTH PROBLEM OR DISABILITY?
  SELECT YES NO
• IF YES, PLEASE DESCRIBE

PERSON TO NOTIFY IN CASE OF EMERGENCY

• FIRST NAME*
• ADDRESS*
• EMAIL*
• HOME PHONE*
• WORK PHONE*

PROGRAM INFORMATION

• TYPE OF CLASSES*
  SELECT Group Private Curso para Profesores
• HOURS PER DAY*
  SELECT 3 4 5 6
• HOMESTAY*
  SELECT YES NO
• DATES YOU WILL BE AT THE SCHOOL

  FROM*

  TO*
• TOTAL NUMBER OF WEEKS AT THE SCHOOL
• DO YOU WANT TO BE PICKED UP AT THE AIRPORT?
  SELECT YES NO
  DATE OF ARRIVAL*
  TIME OF ARRIVAL*
  AIRLINE*
  FLIGHT #*

HOMESTAY INFORMATION

• DO YOU MIND IF THE FAMILY HAS PETS
  SELECT YES NO Doesn't matter
• DO YOU MIND IF THE FAMILY HAS CHILDREN
  SELECT YES NO Doesn't matter
• DO YOU MIND TAKING A BUS TO SCHOOL
  SELECT YES NO Doesn't matter
• DO YOU PREFER TO BE WITHIN WALKING DISTANCE TO THE SCHOOL
  SELECT YES NO Doesn't matter
• IF YOU ARE STAYING WITH HOST FAMILY, DO YOU HAVE ANY SPECIAL REQUESTS?
• DO YOU SMOKE?
  SELECT YES NO
• OTHER PREFERENCES AND COMMENTS
• HOW DID YOU HEAR ABOUT EPIFANIA?
  SELECT INTERNET ADVERTISEMENT FRIEND
• FRIEND'S NAME