EL QUIJOTE - APPLICATION FORM
Saucillo Panoramica Letra "A", C.P. 36000, Guanajuato, Gto., Mexico
Tel: 612-216-4763 (U.S.) or 011-52-473-731-0297 | info@mexicoabroad.com
CHECK PROGRAM OPTION:
Semester I (Plan A)
Semester I (Plan B)
Semester II (Plan A)
Semester II (Plan B)
Summer 200_
Design Your Own
CONTACT INFORMATION:
Name (Mr./Ms.; Last /First /M.I.)_______________________________________________________
Age__________
Present/University Address (Number & Street) _________________________________________________________
City/State/Zip _________________________________________________________
Telephone( )____________________ Fax Number ( ) ______________________________
E-mail ___________________________
Permanent Address (Number & Street) _______________________________________________________________
City/State/Zip _________________________________________________________
Telephone( )____________________
Date of Birth_____/_____/_____ Place of Birth_______________________ Passport No.___________
Citizenship____________________ Social Security No._______-_______-_______ Sex __________
Next of kin or person to notify in case of an emergency:
Name________________________________________ Relationship___________________________
Address____________________________________________________________________________
Telephone Numbers Work: ( )__________________ Home: ( )__________________
Family Doctor __________________________________ Telephone( )______________________
ACADEMIC STATUS
College/University________________________________Major__________________ G.P.A.______
Current Status (Circle one): Freshman/Sophomore/Junior/Senior
Number of years of Spanish taken: High School___________ University_____________
Which of the following levels would best describe your level of oral proficiency in Spanish?
_____Beginner _____Low Intermediate. _____Intermediate.
_____High Intermediate. _____Advanced
MEDICAL INFORMATION
Please answer the following questions and have your doctor sign and date as indicated.
(1) Do you have any on-going medical conditions and/or take any medications? No_____ Yes_____
If so, please indicate the diagnosis and treatment.________________________________________
(2) Do you have a disability? No_____ Yes_____ If so, please describe________________________
(3) Do you have any allergies? No_____ Yes_____ If so, please indicate which allergies and their reactions to each one. Add additional pages if necessary.
ALLERGY REACTION
(1)
(2)
BLOOD TYPE:________________
By signature below, I verify that the medical information provided on this form is correct, and that
(Name of student) _________________________has received a complete physical check up within the last six months.
Doctor's name______________________________Signature_______________________Date________
*Note: Students are required to have their own medical insurance coverage while in Mexico. See Health Insurance option for insurance company recommendations located in the U.S.