Internship Program Admission Form Full name of the participant Genre GenreMaleFemaleNo binaryI prefer don't answer that Date of birth: MM/DD:YYYY University or Institution of afiliation Area of studies or concentration Do you have a valid passport? Do you have a valid passport?YesNo Passport number Email address In wich country was your passport issued? Contact person in case of emergency Telephone number Is there any health condition about which we at CIME or your new Costa Rican host family should be informed? Is there any health condition about which we at CIME or your new Costa Rican host family should be informed?YesNo Please describe any issue or health condition. Do you have any special needs, medications, food restrictions or physical limitations that may require special attention? Do you have any special needs, medications, food restrictions or physical limitations that may require special attention?YesNo Please describe any special need, food restriction or physical limitation Have you ever studied spanish? Have you ever studied spanish?YesNo Using the following scale from 1 to 5, being 1 a beginner and 5 almost bilingual, please rank yourself Write Write12345 Read Read12345 Speak Speak12345 Understand Understand12345 What motivates you to participate in this program?: What field or area are you considering for your internship?: During wich month would you like to begin the Program? During wich month would you like to begin the Program?JanuaryFebruaryMarchJuneJulyAugustSeptemberOctoberNovemberDecember Send Application Form
