High School Spanish Immersion in Costa Rica

Today's Date

How did you hear about this program?*

Do you remember if you were searching online... some sort of advertisement... social Media... a presentation, a family or friend?

Select your Immersion Program*

Do you have custom travel dates?

Please detail length and dates of the trip you've pre-approved with Common Ground leadership

Student Information

Student Name (As on passport)*

First Middle Last

Student Phone*

Student Email*

Student Gender*

Date of Birth*

Age at time of program start?*

Address*

Street Address City State ZIP Code

Parent/Guardian 1 Information

First Name*

Last Name*

Last

Relation to Student*

Cell Phone*

Email*

Does parent/guardian 1 live at the same address you entered above?*

Yes
No

Please provide parent/guardian 1 address*

Street Address City State ZIP Code

Parent/Guardian 2 Information

First Name

Last Name

Last

Relation to Student

Cell Phone

Email

Does this parent/guardian 2 live at the same address you entered above?

Yes
No

Please provide parent/guardian 2 address

Street Address City State ZIP Code

Emergency Contact Information (not Parent/Guardian)

Full Name*

Relation to Student*

Email*

Cell Phone*

Address*

Street Address City State ZIP Code

Passport Information

Is your passport issued by the United States of America?*

Yes
No

What is the nationality/citizenship stated on your passport?

First Last

Name Exactly as on Passport

Passport Number

Date of Issue

Please enter this date as it is on your passport: Month, Day, Year

Date of Expiration

Please enter this date as it is on your passport: Month, Day, Year

Medical Information

Primary Care Physician*

Phone Number*

Medical Insurance Carrier*

Policy Number*

Health Conditions*

Please list and describe any & all health conditionsthat student has. This information is extremely important for us to know to keep your student healthy and happy while abroad. We keep this information strictly confidential.

Medications*

Please list and describe any & all health conditionsthat student has. This information is extremely important for us to know to keep your student healthy and happy while abroad. We keep this information strictly confidential.

Allergies*

Please list any and all allergies to food, insects, medications, etc. Does this participant carry an epipen?

Special Dietary Needs

Please list all special food requirements that student has.

ECUADOR PARTICIPANTS*

It is imperative we know about any and all mental, physical, health factors and medications. We will be out on the trail for 4 days. It is important that we know what we are dealing with in case of any emergencies. Things that might not come to mind but are super important are... - a heart condition -Asma - a severe allergy that requires an epi-pen (insects, food, medications) - a tendency to get overwhelmed and "give-up" Please be detailed in your description below

Has the participant completed the COVID - 19 Vaccination?*

Has the participant completed the COVID - 19 Vaccination?* Please select "yes" if 100% done, "No" if not at all, & "Other" and provide detail if you've not completed your vaccination regimen.

Yes
No

COVID - Underlying Conditions*

Please list any underlying conditions the participant has that may complicate health if participant were to contract COVID 19 while abroad.

Host Family Information

Do you prefer a family with or without children?*

With Children
Without Children

Do you need any special accommodations at your host family?*

Spanish Language Experience

Briefly Describe your Spanish experience*

Please include number of years of Spanish in high school, any related foreign travel, etc.

What Spanish class / level are you currently in?*

Can you comfortably communicate in the present tense in Spanish?

Sí
No

Can you comfortably communicate in the past tense in Spanish?

Sí
No

Can you comfortably use commands in Spanish?

Sí
No

Can you comfortably communicate using the subjunctive in Spanish?

Sí
No

Oral Comprehension*

Speaking Proficiency*

Reading Comprehension*

Writing Ability*

Statement of Purpose / Interest in Immersion Program

Please explain why you wish to participate in this program and what you hope to gain from it.*

High School Information

Name of High School*

Name of Spanish Teacher

Spanish Teacher's Email

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Character References

Participants...we need two references that know you well and can speak of your character, school and community involvement. Please include one teacher and another adult. Please do not include an immediate family member, rather someone from your community (teacher, coach, church, work, etc..Please submit two character reference letters along with this form. You will need to copy and paste the link below in your browser and download this form to follow instructions: https://commongroundinternational.com/wp-content/uploads/2018/01/Character-Reference-Form.pdf

Reference # 1 Name*

How do you know this person?*

Email*

Phone*

Reference # 2 Name*

How do you know this person?*

Email*

Phone*

Thank you for submitting your travel registration form.

We will be in touch with you with next steps. Be sure to hit the submit button below!

Travel Registration – High School Spanish Immersion

High School Spanish Immersion Travel Registration

Whether you’re joining us in Costa Rica or Ecuador – You are going to love your experience

Notes about this Spanish immersion registration for parents & students:

2022 High School Spanish Immersion Registration

Student Information

Parent/Guardian 1 Information

Parent/Guardian 2 Information

Emergency Contact Information (not Parent/Guardian)

Passport Information

Medical Information

Host Family Information

Spanish Language Experience

Statement of Purpose / Interest in Immersion Program

High School Information

Character References

Thank you for submitting your travel registration form.

If you have any trouble completing this registration form, please contact us, we will be happy to assist you.

Impacting Communities Through Language

Travel Registration – High School Spanish Immersion

High School Spanish Immersion Travel Registration

Whether you’re joining us in Costa Rica or Ecuador – You are going to love your experience

Notes about this Spanish immersion registration for parents & students:

2022 High School Spanish Immersion Registration

Student Information

Parent/Guardian 1 Information

Parent/Guardian 2 Information

Emergency Contact Information (not Parent/Guardian)

Passport Information

Medical Information

Host Family Information

Spanish Language Experience

Statement of Purpose / Interest in Immersion Program

High School Information

Character References

Thank you for submitting your travel registration form.

If you have any trouble completing this registration form, please contact us, we will be happy to assist you.

Impacting Communities Through Language

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