Registration Form

PERSONAL INFORMATION

Name: *

Last Name: *

Gender: *

Man

Woman

Age: *

Email: *

Phone Number:

Country: *

Emergency contact Name: *

Emergency contact Number: *

Profession: *

Passport Number:

Pick me up at the airport: *

Yes

AIPORT PICKUP INFO

Pick Up Date: *

Pick Up Time:

Flight Number:

Airport: *

Airline:

SPANISH PROGRAM

Length of Program desired for both Campuses:

Classes dates in Heredia (City Campus)

Classes in Heredia From:

Classes in Heredia To:

Classes dates in Samara (Beach Campus)

Classes in Samara From:

Classes in Samara To:

Approximate Spanish Level:

ACCOMMODATIONS

Prefered Accommodation Type: *

Homestay

Hotel Room

ACCOMMODATIONS - HOMESTAY

Heredia Homestay

Heredia Homestay From:

Heredia Homestay To:

Homestays are from Sunday to Sunday. Students may add up to a maximum of 4 additional nights with their host family. After 4 nights, the full week rate will be charged.

Samara Beach Homestay

Samara Homestay From:

Samara Homestay To:

Homestay Comments:

Please indicate if you have any special requests regarding the homestay family. Furthermore, please let us know if you have allergies, health problems, food restrictions or if you are a vegetarian. Please tell us any interests and hobbies that you have.

ACCOMMODATIONS - HOTEL (Samara Campus only)

Samara Hotel From:

Samara Hotel To:

Hotel Type:

Room Type:

Hotel Options:

MARKETING INFORMATION

How did you hear about Intercultura?

Which site did you find us on?: *

Were you referred to Intercultura by: *

Please specify:

What were the primary reasons you chose Intercultura?: *

Additional Comments

Comments:

Terms And Conditions

I have read and agree to abide by Intercultura's Cancellation and Refund Policy (click here to read) and the penalities described in the Important Information below. I am aware of the National Holidays and Visa.

I agree: *

Yes

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