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Personal Information
First Name (as in the passport)
Last Name (as in the passport)
Nickname
Sex
Birth Date
Nationality
Level of Spanish completed by the time of the trip
School you teach in (if an ACPS teacher)


Address
Apt# / Street 
City and State
Postal Code 
Telephone 
Fax
E-mail
Emergency E-mail
Telephone # and name of a responsible person for emergencies


Family
Special dietary needs No
Vegetarian
Others 
I would rather live with a family with children
without children


Health
Any restrictions for OTC drugs?
Any allergies? No  Yes 
Other medical concerns:
Insurance company:
Your Dr. Dr. phone #

Comments:

Thank you for your interest in Casa Xelajú