1. Basic Information First Name Last Name Birth Date Nationality 2. Contact Information Email Phone Profession Hobbies 3.Emergency Contact Emergency Contact Telephone 4. Previous Knowledge Of Spanish: Basic (A1)BASIC (A2)Independet (B1)Independet (B2)Proficient (C1)Proficien (C2) 5. Would you like to discover Galapagos while you learn Spanish? Select a Program SPANISH LESSONS & 10 DAYS TOURSPANISH LESSONS & 8 DAYS TOURSPANISH LESSONS & 7 DAYS TOURSSPANISH LESSONS & 5 DAYS TOURSONLY SPANISH LESSONS IF YOU CHOOSE ¨ONLY SPANISH LESSONS¨ PLEASE, TICK THE SPANISH PROGRAM YOU WISH TO TAKE. ONE LESSON PER DAY ( $ 20 USD)15 LESSONS PER WEEK ($225 USD)20 LESSONS PER WEEK ($300 USD) 6. Date You Wish To Begin To Study: Select Star Date Number of Weeks Do you require accommodation? YesNo IF YOUR ANSWER IS ¨YES¨ TO THE ABOVE QUESTION, PLEASE SELECT ONE OPTION HOMESTAYGUEST HOUSE AND HOTELSAPARTMENT Date of arrival Date of departure Do you smoke?YesNo Do you have a special diet?YesNo Do you have any medical conditions? YesNo Do you have any allergies? YesNo Please provide details if your answer to any of the above 3 questions is “Yes” or if you have any other special requests: 7. Do You Wish To Be Met At The Airport In Baltra? (It will cost you $50 dollars to pick you up at the airport or $25 at the Chanel Itavaca) YesNo Fly Date Airline Company Flight Number Time of Arrival 8. Do you have any question or special needs? TO ENSURE YOUR RESERVATION YOU HAVE TO MAKE A DEPOSIT OF AT LEAST 10% OF THE PRICE.