NO DEJAR ESPACIOS EN BLACO, COMPLETE TODAS LAS PREGUNTAS.

Emergency Contact Information

Name
Phone number
Alternate Phone number
Relationship
Country DR

Can Speak English? Yes No

if no,what language?
Criminal Background
Have you ever been convicted of a crime? Yes No
No

if yes, explain

Program Information
Program Length Desired

Summer
Program

Preferred Arrival Date / /

Preferred Departure Date / /
Reasons for participating in this program

Previous Work Experience

Company What did you do there ? Time Period
mm/yy - mm/yy

Special skills:
Name of College/University you attend

Language Skills- Please list languages you have known/studied and rank your proficiency.
Language Years Studied Speaking Reading Writing
English

Hobbies
Please list hobbies, interest, sports in which you are interested:

Health Background
Allergy Yes No
Mumps Yes No
Asthma Yes No
Physical Handicap Yes No
Cancer/Tumors Yes No
Psychological Disorder Yes No
Convulsive Disorder Yes No
Rheumatic Fever Yes No
Diabetes Yes No
Rubella Yes No
Chicken pox Yes No
Scarlet Fever Yes No
Dyslexia Yes No
Substance abuse Yes No
Eating Disorder Yes No
Thyroid Disease Yes No
Eczema Yes No
Ulcer Yes No
Hepatitis Yes No
Urological problems Yes No
Measles Yes No
Whooping Cough Yes No
Migraine Headaches Yes No
No

Other Conditions

Do you require any special consideration Yes No

Explain the treatment (if yes)

Need to take any prescribed medication during stay? Yes No

if yes,explain the medication