Yelapa English Spanish Institute
Tel 011 52 322 2095220
[email protected] http:// www.talkadventures.com
Medical Spanish Registration Form (Please fill in and EMAIL MSWord document to [email protected] )
1 . Name: Age: Sex:
2 . Address:
3 . City: Postal Code /Zip Code
4 . Telephone Fax: Email:
5. Weeks of Spanish Classes : 1 week ___ $350 US /$ Can (equivalent); 2 wks ___ $650 US/ $ Can (equivalent)
6. Class Dates
Level 1 - Feb 4-11 Level 2 - Feb 11 - 18
Level 1 - March 18-25 Level 2 � March 25-31
7. Language Experience 1 2 3 4 5
Beginner Intermediate Advanced
8. Previous Spanish studies taken : None Formal Informal/Self Study Immersion (# weeks)
Are you comfortable using: verbs past tenses object pronouns commands subjunctive
When did you last study Spanish? For how long?
9. Participate in the Guided Activities? Yes No No. of People (#)
List activities of interest :
10. Accommodation (Please BRING PAYMENT to Yelapa, DO NOT pay YESI):
Would you like to arrange your own? ___ Yes ____ No
What accommodation would you prefer:
__________ Home-Stay (one/room with 2 meals) $200 US / $Can equivalent
__________ Private Suite from $245 US/ wk or $Can equivalent
__________ Hotel Lagunita $490 US / $640 Can/ wk
11. Additional Fees Include
Registration- $25US/$30 Can Equiv Accom Placement �Private $30US/$ 35Can, Homestay $20US/25 Can; Materials* Levl 1 - $55 US approx. / $Can equiv. Lev 2 - $73US/$ Can equivalent
12. Medical Condition: Any physical condition for which you are receiving medical treatment or medication? Yes No
Please indicate details of condition and medications required:
13 . Any Allergies or Food Restrictions ? Yes No Specify
14. Contact Name and Address of Nearest Relative or Friend :
Name: Relationship: Tel.: ( )
Address: City: Postal Code
15. Flight Arrangements : (if known)
Payment Options : Deposit $75 with Registration, and Full Payment required two (2) weeks prior to arrival
• Mail cheque or money order, (if at least 2 weeks prior to course date) made out to Jean Hnytka , and send to :
North Shore Credit Union , Box 952 Pemberton , B.C. Canada V0N 2L0 Address Attn: Denielle Shapansky
or transfer from other Credit Unions.
2. Paypal for American and Canadian students. Sign in with www.paypal.com
a) For NON CREDIT CARD payments and Debit cards email funds to [email protected] ;
b) For CREDIT CARD payments email [email protected]
3. Hyperwallet for Canadian only students to account #CS633879846 www.hyperwallet.com for registration.
4. Please email your registration [email protected] . Please state method of payment, and date of deposit. Gracias
* Materials and Texts Used will be Provided at Cost � Binder of Materials ( Grammar and Medical Terminology and Medical Readings), Medical Dictionary, Medical Diagnostic Phrase Book, and (Lev 2 only) Intermediate Spanish Grammar Text