Spanish School ICA Application/Registration Form

Enrollment Application - Spanish School ICA
Please Read:All payments will appear on your credit card statement as: Mary Lingenfelter - Alameda, CA. Questions: Email: Mary Lingenfelter Phone in USA (Voicemail) +206 888-1778 In Guatemala: +502 7761-4396 Payment: Registration Fee $15.00 + 1 Weeks Tuition - Spanish School ICA.
Please fill in all fields, those marked with an * are required.
	Your First Name and Middle Initial as it appears on the card	*
	Your Last Name as it appears on the card	*
	Name(s) of Student(s) if different
	Age of student(s)
	Sex: Male or Female	Female Male
	Your Passport Number - Optional
	Street Address	*
	City	*
	State	*
	Zip or Postal code	*
	Country	*
	Home Phone
	Fax Number
	Email (check for accuracy)	*
	Profession/Occupation
Arrival & Knowledge Information
	Date you will arrive in Guatemala City?
	Do you want pickup service in Guatemala City?	Yes No
	Which Airline? (leave blank if arriving by land)
	Time of arrival in Guatemala City?
	Date you will arrive in Xela? (mm/dd/yy)
	Date you will start classes? (mm/dd/yy)
	How many weeks will you study?
	Spanish Level: Poor, Fair, Good, Excellent?	Poor \| Fair \| Good \| Excellent
	Do you want a Family Home Stay?	YES \| NO \|
	How did you hear about us? (Xelapages, Google, Yahoo, Friend...etc) Be specific
	Have you ever studied Spanish?	Yes \| No
	If yes, when, where and for how long?
Emergency Contact Information
	In case of emergency contact
	Contact Phone #s: Home & Work
	Contact E-mail
	Relationship
	Special dietary or medical needs. (Vegetarian Meals, Food Allegies..etc.)
	In which Study Program do you wish participate? Single Package I 25 hours of Spanish classes September to May: U.S.$180 + $15 = $195.00 1st Week June to August: U.S.$190 + $15 = $205.00 1st Week Single Package II 20 hours of Spanish classes September to May: U.S.$160 + $15 = $175.00 1st Week June to August:U.S.$170 + $15 = $185.00 1st Week Duo Package I 25 hours of shared Spanish classes (2 students) Price per person, per week: September to May:U.S.$290 + $15 = $305.00 1st Week June to August:U.S.$300 + $15 = $315.00 1st Week Duo Package II 20 hours of shared Spanish classes Price per person, per week: September to May: U.S.$270 + $15 = $285.00 1st Week June to August:U.S.$280 + $15 = $295.00 1st Week
Credit Card Information Non Refundable Registration Fee: $15.00 per student. This fee is valid for 2 years. If needed you may change your arrival date with advance notice.
	Card Type
	Enter Transaction Amount - ENTER ONLY NUMBERS - All payments are in USD $.	$ * Enter Transaction amount in numbers
	Card number with NO spaces	*
	Card Expiration Month	*
	Card Expiration Year	*
	CVV - Security Code on card - How to find my CVV?	*
Please be patient processing may take up to 2 minutes. ONLY click the submit button once. Printable receipt page will appear once payment is approved