ON-LINE APPLICATION EMPORIA STATE UNIVERSITY Application Form for “Study abroad in Costa Rica Program 2002”. Please copy and paste the following form and send it to the following address. For Registration fill out the following form and send it with a picture and a deposit of $100 non-refundable to the following address: Dr. Luisa Perez Emporia State University Department of Modern Languages and Literatures Campus Box 4024 Emporia, Kansas 66801-5087 Personal information I would like to enroll in the following program: Number of weeks you plan to study:2______3_______4_______more______ MONTE VERDE_____FLAMINGO BEACH_____HEREDIA______ Accommodations: Homestay____Bed & Breakfast______apartment_______ Hotel___________________________________________________________________ LAST                    FIRST NAME         MIDDLE INITIAL Sex: Female________Male_________Age_______Marital status: Single____ Married___________ Permanent Home Address: __________________________________________________________ STREET                   ____________________________CITY_____________________   STATE   _____________________________COUNTRY ________________________   ZIP CODE ___________________________ Phone Number:(____)___________EMail:___________________________ Passport #:_______________________________________ Name, address, and a telephone number of person to contact in the case of emergency: What is your native language?___________________________ Spanish Level information : Beginner_______ Intermediate______ Advanced________Superior_______ How did you learn about the summer program of “Study abroad in Costa Rica:______________________ Health  status/Allergies________________________________________ Name of insurance: _____________________________(make sure the your insurance covers you overseas) Hobbies/Interests________________________________________________________________________ Host Family information: Answer “Yes” ,”No” or “Either” Do you Smoke? ________  Do you like pets?_______  Would you like a family with children?________Do you have any dietary requirements?__________________________________________________ Do you have any physical or emotional disability that we should take into consideration in choosing an appropriate host family for you?____________________________________________________________ Are you traveling with a companion?_____________ If the answer is yes, would you like to be placed with the same family. Same room_______, private room_____ single bed ________ Full size bed(for 2)_____ If you feel there is anything else we should know in order to best place you with a compatible host family, please so indicate below:_________________________________________________________ I have read and agree with all the terms & conditions on the back of this application Student’s Signature: __________________________Date:__________ Parent signature(if younger that 18)____________________________ Registration and payment To register submit a completed application with a $100 non-refundable deposit.  The total cost for all group programs is due 9 weeks prior to the start date.