Application Form "Please fill out the application form if you are going to apply. If you would like more information please contact us:ipedcostarica@gmail.com" If you send in an application or any email and don't hear back from us within 24-36 hours it means we have not received it. We seem to be having some problems with the one and only national internet service provider. Please, write to us and let us know that you did not get a reply. * Fields Required First name* Middle Initial Last name* Address1* Address2: City* State Zip Country* e-mail* Phone* Fax Occupation* Age* Male/Female* Person to notify in case of emergency: First name* Last name* Phone* e-mail* Are you with a Group?*NoYes Group name: Group leader: Previous Spanish*No Yes Level of Spanish: Basic Intermediate Advanced Superior How many weeks of classes are you registering for?: (Check one)* 0 1 2 3 4 5 6 7 8 More Spanish Language in Heredia Weeks: 0 1 2 3 4 5 6 7 8 More Spanish Language in Puerto Viejo Weeks:* Date you would like to start classes: Would you like a Costa Rican Homestay Program?* No Yes Do you have any medical conditions or preferences we should know about?* No Yes (if your answer is yes, use the "comments" field to specify) How did you learn about this program: Outside Magazine World Wide Classroom America OnLine WWW Home Page Other Student Article Newspaper Add Tico Times Costa Rica Today Travel Book School Flyer Other Specify Yes! Make reservations for the above mentioned course. Comments: <-- Insert Comments -->