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.