ENROLLMENT FORM

I. Personal Information
First name:
Last name:
Nationality:
Birthday:
Sex:
Male
    Female
Profession:
Street Address:
Zip code:
State/Province:
City:
Country:
Telephone (home):
Fax:
Telephone (work):
Passport number#:
E-mail:
 Ethnic origin:


II. Arrival Details
Airport pick up:
Yes No
Arrival date:
Time:
Airline:
Flight #:
 Contact in case of emergency:
Medical concerns:
Yes No
Add Info :
 


III. Host Family Information
In San José:
Yes No
First day:
Last day:
In Manuel Antonio:
Yes No
First day:
Last day:
Do you mind if the host family has:
Smokers?
Yes No No pref.
Children?
Yes No No pref.
Pets?
Yes No No pref.
Another student?
Yes No No pref.
Are you a smoker?
Yes No
Hobbies / Interests:
Additional comments:


IV. Program Information
Select the type of program you want (you can select more than one) and its starting and ending dates:
(includes airport pick up and bus transfer from San José to Manuel Antonio)
San José Program

Option A: group 4 hrs/day
Starting date:
Ending date:

Option B: private tutoring 4 hrs/day

Starting date:
Ending date:

Option C: group 4 hrs. + 2hrs. private tutoring

Starting date:
Ending date:

Manuel Antonio Program (Beach and Rainforest site)
Option D1: beach group. Starting date: Ending date:
Option D2: beach private tutoring.
Starting date: Ending date:
Option D3: beach group + 2 hrs. private tutoring.
Starting date: Ending date:
Comments regarding Program Information:


V. Apartment in San José (100 mts from COSI, 3 bedrooms (double bed in each), full furnished, includes cable with internet access and TV)

Sharing apt (priv.room):

$30/night; $160/week; $500/month
(+30% if it is a double)
Starting date:

Whole apt:
$60/night; $350/week; $1200/month
Ending date:

VI. Other Information
Spanish level:
Other languages spoken:
How did you find out about COSI?:
Other information:


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Part of your payment helps to fund environmental protection as well as the education and well being of disadvantaged children, through donations to ASCOMOTI (protection of the squirrel monkey) and the Fundación Piedad which runs schools for children from poor neighbourhoods.