Kohler / M�ndez International Enterprises
Home Study Program

Registration Form

Name: _____________________________________________________________

(Last)                                                      (First)

Address: ____________________________ Telephone: (____)___________

City: _________________ State: ______________  Zip: __________ Fax: (___)_____________

Date of Birth:____________ Age: _________ Grade level in school: ______

High School/City:_________________ Years of Spanish Studied: ___________

Level of Spanish: Basic: ______  Intermediate: _______  Advanced: ______

In Case of Emergency, Notify:

Name: __________________________ Relationship:______________

Address/City:______________________________________

Home Telephone: _____________  Business Telephone: ____________  Fax: _______________ 

Please indicate any physical injuries, drug allergies, and/or requirements for special medical or dietary treatment (including religious restrictions): _____________________________________________ 

______________________________________________________________________________

Special interests or hobbies:___________________________________________ 

Name(s) of preferred roommate(s):______________________________________

For conflicting times and dates:

Enrollment date: ______________ Date of arrival: ________________

Length of stay: ______________________________________ (weeks)

Starting Date: ________________ Ending date: __________________

Please enclose with your registration form, your registration check for $175 (non-refundable) made payable to Tina M�ndez-Kohler or Bob Kohler.