Travel Registration: Medical Immersion & Int'l Rotation

You are going to LOVE this trip!

Notes about this medical Spanish immersion travel registration:

Have your passport*, medical insurance, and emergency contact information handy to complete this program registration.
Once you’ve completed this registration, continue with the next steps in your online pre-departure course with tons of necessary information about your trip, and a few travel contracts to sign.

*You absolutely need a passport for travel to Costa Rica. Passport fields are not “Required” fields on this registration form, so you will still be able to submit your registration even if you don’t have a valid passport currently.

If you have any questions or need special arrangements, contact us!

No problem if you can’t fill out this registration form all at once. On the bottom of this form, you can see an option to “Save and Continue Later”. Go ahead and get started!

"*" indicates required fields

Select Your Immersion Program

Which Spanish immersion program are you registering for?*

Personal Information

Name*

First Last

Profession/Area of Study*

Grade level / Subject Area

Cell Phone*

Email*

Please provide an email address that you check regularly. Program updates and documents will come to you primarily via this email address.

Gender Identity*

Please add your preferred pronouns here as well

Date of Birth*

Month

Day

Year

Address*

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

Will any children, family members or special friends accompany you?*

Yes

Please list each of the family members traveling with you:

First & Last Name

Sex

Date of Birth

Passport # & Expiration Date

Allergies (food, pets, etc)

Emergency Contact Information

Name*

First Last

Relation to Traveler*

Email*

Cell Phone*

Address*

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

Passport Information

Name Exactly as on Passport

First Last

Passport Number

You absolutely need a passport to travel in and out of Latin America, however this section is not required to fill out your application in case you don’t have one yet or it needs to be renewed. Please fill out this information if you have a valid passport.

Was your passport issued by the United States of America

Yes

From which country was your passport issued?

Date of Issue

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

YYYY

Date of Expiration

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

YYYY

Medical / Health Information

Primary Care Provider*

Phone Number*

Medical Insurance Carrier*

Policy Number*

Health Conditions & Medications

You will participate in a variety of experiences during this trip that may require medical support. Please list any health conditions (physical, mental, etc.) and medications that we should know of. It’s particularly important to include conditions exacerbated by stress, fatigue, altitude, heat, etc. This information is kept strictly confidential; please include everything that will help us keep you safe and healthy while traveling abroad.

Environmental, Pet, Medication, Insect Allergies

Please list any and all allergies to insects, pets, medications, etc – Your host family needs to know this information and we need it to make a good host family placement for you.

Food allergies and sensitivities

Please list any and all medically relevant food allergies or sensitivities that you have. Ex. Allergic to nuts, celiac diagnosis, certain fruits, etc.

Regarding special diet preferences (vegan, vegetarian, etc), we respectfully ask that you consider a flexible approach during your travels understanding that most of the time your preferences will be accommodated but that sometimes they may not be.

Host Family Information

Are you a smoker? (or anyone traveling with you)*

Yes

Do you prefer a family with or without children?*

With Children

Without Children

Doesn’t matter

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

Please be sure to mention any food or pet allergies, mobility mobility requirements, etc. that you have so that we can make an adequate host family placement for you.

Is there another traveler on the program that you would like to share a host family with?

If not, no worries, we’ll make a good pairing based on your host family preferences listed above. But if you’re traveling with a friend, classmate, spouse or partner, we would be glad to consider pairing you together. Please list their name below.

Spanish Language Experience

Are you able to comfortably communicate in the present tense in Spanish?

Sí

No, ayúdame

Are you able to comfortably communicate in the past tense in Spanish?

Sí

No, ayúdame

Are you able to comfortably communicate using commands in Spanish?

Sí

No, ayúdame

Are you able to comfortably communicate using the subjunctive in Spanish?

Sí

No, ayúdame

Oral Comprehension*

Speaking Proficiency*

Reading Comprehension*

Writing Ability*

Briefly Describe your Spanish experience*

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

What is your current language ability and experience with Spanish?

Please give a short description of each family member’s experience with the Spanish language, or let us know in case you don’t have any experience.

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.*

Travel Registration: UNCW Medical Spanish Immersion

You are going to LOVE this trip!

Notes about this medical Spanish immersion travel registration:

If you have any questions or need special arrangements, contact us!

Select Your Immersion Program

Personal Information

Emergency Contact Information

Passport Information

Medical / Health Information

Host Family Information

Spanish Language Experience

Statement of Purpose / Interest in Immersion Program

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