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Personal Information
First Name
Last Name
Sex
Birth Date
Nationality
Please e-mail your passport # when you ge it
Mother Name
Father Name
Spanish Year
Your teacher´s name


Address
Apt# / Street 
City and State
Postal Code 
Telephone 
Fax
E-mail
Parent´s 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
Do you have any medical problem? No  Yes 
Do you have any allergies? No  Yes 
Others
Would you like to play soccer?
No Yes
Which position?
 
Would you like to play basketball
No Yes
Which position?

Comments:

Thank you for your interest in Casa Xelajú