IMPACT-LLS (Language Learning & Service) Spain Application 2015

Spain 2015: Language, Culture & Service

Sponsored by: IMPACT-LLS (Language Learning & Service) Inc. and Entrelenguas
Student Application and Deposit Form
Full Name *

Last Name First and Middle name
Sex *
T-Shirt Size *
Birth Date *

Month Day Year
Address *

Billing Address

Billing Address (Line 2)

City State / Province

Postal / Zip Code Country
Home Phone Number (Land Line) *

Area Code Phone Number
Student Mobile Phone *

Area Code Phone Number
Personal E-mail
Parents and Emergency Contacts
Mother Name *

First Name Last Name
Mother Mobile Phone *

Area Code Phone Number
Personal E-mail
Father Name *

First Name Last Name
Father Mobile Phone *

Area Code Phone Number
Personal E-mail
Guardian 1 Name

First Name Last Name
Guardian 1 Mobile Number

Area Code Phone Number
Personal E-mail
Guardian 2 Name

First Name Last Name
Guardian 2 Mobile Number

Area Code Phone Number
Personal E-mail
Emergency Contact *

First Name Last Name
Mobile Phone Number *

Area Code Phone Number
Personal E-mail
Passport Information
Passport Name *

Last Name First, Middle
Place of Birth *

State Country
Passport Number *
Date of Issue

Month Day Year
Date of Expiration

Month Day Year
Medical Information
The medical information provided on this form is confidential and will only be shared with the staff that will be working with your child and to the host family. It is imperative that all health issues be shared so that we can determine the best course of action for your child in the event of a medical emergency. Providing this information could be a key factor in the event of an emergency situation.

We also respectfully request a copy of your child's most recent physical for our records, as this information will be helpful and necessary. In addition to any pertenint medical information, any behavioral or psychological conditions or disorders should be mentioned below. If your child is seeing a therapist, please share the doctor's contact information in the event of a personal crisis.

IMPACT hires the most qualified teachers and adminstrators in the world to work with your children. We are not staffed with an "on site" social worker or psychologist, but we do have a service on call for emergency reasons. For reasons of liability, it is imperative that all emotional/psychological health information is also shared so that we can put an action plan into place in the event of an emotional crisis.

Failure to comply with this agreement will result in being charged the emergency hourly rate for the services IMPACT-LLS retains in the United States. If the situation is untenable and the student requires serious medical attention or the student places an extraordinary burden on the support staff that exceeds beyond the scope and responsibilities IMPACT-LLS/Entrelenguas, IMPACT-LLS will withdraw the student from the program, and the child will be sent home at the parent/guardian's expense.
Current Health of my child *
Please provide a detailed descripton of any medical issues that your child has experienced. If your child will require special accommodations, please let us know here: *
Please provide Doctor's names and contact information *
Does your child require the administering of medication? *
Please provide the medication and all instructions for its use, its side effects, and who can administer the meds: *
Does your child have any allergies? *
Please list any allergies and courses of action in the event of an allergic reaction: *
Are there any behavioral or psyschological issues or conditions about which we should know? *
If yes, please provide a detailed description and doctor's contact information: *
Home Stay Preferences
All families have gone through a comprehensive screening, which includes a criminal background check, a home inspection, and a persoal interview. We tend to favor families with previous hosting experience, with small or adolescent children, and most importantly, all families must have a genuine interest in working with your child.
Home Stay Preference *
Do you have any food alergies or special diet? *
Please provide a detailed list of the allergies, what foods can and cannot be eaten, and any other helpful information: *
Are you a vegetarian? *
The Spanish-Meditarranean diet is heavy on fish, seafood, and various meats. Is there any concern with this diet? *
Please list any concerns: *
Language Course History and Language Skill Self-Evaluation
Upon arrival, students will take a brief placement exam that will carefully examine six major criteria: vocabulary knowledge, familiarity of grammar, speaking, listening, writing, and reading abilities. Upon completion of the exam, students will be placed in the appropriate level of their ability. All levels are immersion-based classes, which means that all content will be taught in the target language (Spanish). The pacing will be swift and participation is crucial to the learning process.
Language Experience (Please check all that apply) *

Middle School (6-8) High School Spanish (Beginner) (Spanish 1 and 2) High School Spanish (Intermediate) (Spanish 2 and 3) High School Spanish (Advanced) Spanish 4 and 5 Study Abroad (one to six months) Study Abroad (6 months or more)

Please self rate your speaking ability *

	1	2	3	4	5

1 is Worst, 5 is Best

Please self rate your reading comprehension *

	1	2	3	4	5

1 is Worst, 5 is Best

Please self rate your writing skills *

	1	2	3	4	5

1 is Worst, 5 is Best

Please self rate your listening comprehension *

	1	2	3	4	5

1 is Worst, 5 is Best

Please list some personal and academic goals that you have for this program: *
Desired Language Class Placement *
Tuition and Payment:
The estimated program cost is: *$6,199.00 As soon as we collect the first deposit, we will begin searching for the best airline tickets available. This program cost includes: airfare, home stay (3 meals per day), travel insurance, mobile phone in Spain, instruction, classroom and instructional materials, school building lease, local transportation, admission to all museums and cultural events.

SPENDING MONEY IS NOT INCLUDED IN THIS PRICE.

*Prices may rise slightly to accommodate shuttles or transports out of Salt Lake City and we will keep you informed in the event of a price increase.

Payments can be made by check or by Credit Card through Paypal (a 3% credit card fee rounded up to the nearest dollar will be added to the total amount).

Payment Options:

Plan: D1

This plan divides your tuition into two simple payments after your initial deposit.

Tuition: $6,199.00

Deposit: $1,500.00
Payment 1: $2,350.00
Payment 2: $2,349.00

Plan: D2

This plan divides your tuition into three simple payments after your initial deposit.

Tuition: $6,270.00

Deposit: $1,500.00
Payment 1: $1,590.00
Payment 2: $1,590.00
Payment 3: $1,590.00

Plan: D3

This plan divides your tuition into four simple payments after your initial deposit.

Tuition: $6,320.00

Deposit: $1,500.00
Payment 1: $1,205.00
Payment 2: $1,205.00
Payment 3: $1,205.00
Payment 4: $1,205.00

Plan: D4

This plan divides your tuition into five simple payments after your initial deposit.

Tuition: $6,375.00

Deposit: $1,500.00
Payment 1: $975.00
Payment 2: $975.00
Payment 3: $975.00
Payment 4: $975.00
Payment 5: $975.00

Plan: D5

This plan divides your tuition into six simple payments after your initial deposit.

Tuition: $6,420.00

Deposit: $1,500.00
Payment 1: $820.00
Payment 2: $820.00
Payment 3: $820.00
Payment 4: $820.00
Payment 5: $820.00
Payment 6: $820.00
Ple ase make checks payable to:

IMPACT LLS c/o Laura Davenport

P.O. Box 6

Kelly, WY 83011
What Payment Plan do you choose? *
Method of Payment *
How will you pay?
*For PayPal Payments only
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IMPACT-LLS Deposit (3% Fee Added) $ 1,546.00

Pay in Full (3% Fee Added) $ 6,385.00
Signature *

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Spain 2015: Language, Culture & Service

Student Application and Deposit Form

Parents and Emergency Contacts

Passport Information

Medical Information

Home Stay Preferences

Language Course History and Language Skill Self-Evaluation

Tuition and Payment:

Plan: D1

Plan: D2

Plan: D3

Plan: D4

Plan: D5