ICA Reservation Form

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I.C.A. Enrollment Form

Please fill out the following form carefully so that we may match you with the family and teacher who will best meet your needs. This form will be receive in our Guatemala office and you will get a confirmation in between 48 hours after we receive this application.

Note:

It is required that you send us a payment for the first week to our contact person in the USA, you can do it by sending a Personal Check or Money Order, Payable to Bonnie Barth to the following address:

Bonnie Barth
83969 570 Avenue
Stanton, NE 68779
USA

Tel/Fax (402) 439-2943
dbbarth@stanton.net

You will get a a note from our contact person after the payment is received.

:: Name:
:: Date of Birth:
:: Street Address
:: State, Province or Department:
:: Country:
:: Zip Code or Postal code:
:: Phone (include area code):
:: E-mail address:
:: Occupation:

::Highest Education:
:: If other (please describe):

Spanish Education Background:

:: Have you ever studied Spanish?

yes

::How long ago?

Please rate your present knowledge of Spanish:

Speaking:	none	poor	fair	good	excellent
Reading:	none	poor	fair	good	excellent
Writing:	none	poor	fair	good	excellent

Please describe briefly your goals and reasons for learning Spanish:

Any other information you feel will be helpful to us in selecting a teacher for you:



Personal Information The following information will be used to select your host family:



:: Special dietary needs: yes no

If yes please select:

:: Vegetarian (no meat, poultry or fish)
:: Vegan (no meat, poultry, dairy products or eggs)
:: Food allergy :
::Other (please describe):
:: Relevant allergies (wool, food allergies, dogs or cats, etc.)

Please check one:

:: I would prefer to have a lot of privacy
:: I would prefer to have a lot of contact with my host family

Please describe briefly your expectations or hopes for life with your host family: Any other information you feel will be helpful to us in selecting a host family for you:

What day do you plan to arrive?

How long do you plan to study?

Upon receipt of this enrollment form, we will hold a space for you at I.C.A.

*** Please let us know if your plans change.

US Contact

ICA
83969 570 Avenue
Stanton NE 68779
U.S.A. Phone & Fax: (402) 439 2943
dbbarth@stanton.net