APPLICANT

Name
Occupation
Date of Birth	mm/dd/yy
Sex	Male Female
Passport #
Country of Issue:

ADDRESS

Street
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail

EMERGENCY CONTACT

Name
Relationship
Country
Home Phone
E-mail

GUATEMALAN HOMESTAY

Do you prefer to be housed with a Guatemalan family?

YES
NO

Do you prefer a family:

with children
without children
with Guatemalan students

Please describe any allergies (e.g., cats, smoke), special dietary needs (e.g., vegan, vegetarian), or homestay requests (e.g., roomate, specific family placment):

Level of Spanish skill:

Beginner
Intermediate
Advanced

How did you hear about the school?

(please choose from list) Doctors Without Borders AMSA (American Medical Students Association) NASW (National Association of Social Workers) Former Student Word of Mouth Link on Xelapages.com Other--please specify below

If answer is Other, please specify.

Please describe briefly any particular interests you have that would help us plan your program of study:

ARRIVAL

Date of arrival in Xela:

mm/dd/yy

Monday start date:

mm/dd/yy

Number of weeks you wish to reserve:

Would you like to be met at La Aurora International airport in
Guatemala City?

Yes
No

If yes, please fill out the following:

Airline: 

Date of arrival:

mm/dd/yy

Flight number:

Time of arrival:

Would you like to stay with a host family in Guatemala City for the night?

Yes
No

If not attending a Special Program, scroll to the bottom of the page and click Submit. Otherwise continue by filling out the appropriate section below and then Submit.


FOR MEDICAL STUDENTS ONLY

What is your level of medical training? Please include medical school, residency, nursing, midwifery, public health training, and dentistry.

If still a student, please specify current level of study and future plans:

What is your previous experience outside of formal schooling, including research, volunteerism, travel with medical/public health emphasis, etc.:

What do you hope to accomplish during your stay in Xela?

What is your current level of medical Spanish? Please be specific: none; some but may need interpreter; can perform history and physical if clinical picture is uncomplicated; trauma Spanish.

Of the options listed on the medical pages on this Web site, which might suit you best? Bear in mind that these options are to help find the right setting for you but are not a guarantee of your placement in said workspace.

FOR SOCIAL WORK OR COMMUNITY-ORGANIZING STUDENTS ONLY

What is your level of social work, union organizing, sociology training? Please include graduate or undergraduate schools or specific training and workshops.

If still a student, please specify current level of study and future plans:

What is your previous experience outside of formal schooling and professional training, including research, volunteer work, travel with emphasis on social work, community development, union organizing, etc.? What do you hope to accomplish during your stay in Xela?

What is your current level of social work/professional Spanish? Please be specific: none; some but may need interpreter; can take history and interview for information if circumstances are uncomplicated; any legal-profession Spanish terminology.