Personal Details

mm/dd/yy

Address and Contact Details

Emergency Contact

Guatemalan Homestay

Spanish Skills and Interests

Arrival and Timeline

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mm/dd/yy

mm/dd/yy

Medical Spanish

Name

Occupation

Date of Birth

Sex

Passport No

Country of Issue

Street

City

State/Province

Zip/Postal Code

Country

Work Phone

Home Phone

E-Mail Address

Name

Relationship

Country

Home Phone

E-Mail Address

Would you like to stay

with a Guatemalan Family ?

Do you prefer a family

Please describe any allergies

(e.g. cats, smoke) special dietary

Level of Spanish skill

How did you hear about the school

If answer is Other, please specify.

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

Date of arrival in Xela

Monday start date

Number of weeks you

wish to reserve

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

Airline

Date of arrival

Flight number

Time of arrival

Would you like to stay with a host family

in Guatemala City for the night?

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, volunteering, 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.

Calendar ?

Calendar ?