Yelapa English Spanish Institute
Tel 011 52 322 2095220 Mex 1 800 884 5669 Can
yesi@talkadventures.com http:// www.talkadventures.com
Medical Spanish Registration Form (Please fill in and EMAIL as MSWord document )
1 . Name: Age: Sex:
2 . Address:
3 . City: Postal Code /Zip Code
4 . Telephone Fax: Email:
5. Weeks of Spanish Classes : 1 week ___ $380 2 wks ___ $700
6. Class Dates* _____ Mar 8 - 15 /08 (Indicate Lev 1 or 2) * Please Inquire about Other Dates
7. Language Experience
1 (Beginner) 2 3 (Intermediate) 4 5 (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) $210
__________ Private Suite from $280/ wk
__________ Hotel Lagunita $490/wk
11. Additional Fees Include
Registration- $30 Accom Placement –Private $35/ Home stay $25 Materials* Binder - $15 Additional Texts - approx. $55 (inquire)
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
1. 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
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 yesi@talkadventures.com ;
b) For CREDIT CARD payments email yelapa2002@hotmail.com
3. Hyperwallet for Canadian only students to account #CS633879846 www.hyperwallet.com for registration.
4. Please email your registration yesi@talkadventures.com . 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